Official Report (Hansard)

Session: 2008/2009

Date: 23 October 2008


Evidence Session on the ‘Review of the Outbreak of Clostridium Difficile in the Northern Health and Social Care Trust’

23 October 2008

Members present for all or part of the proceedings: 
Ms Sue Ramsey (Temporary Chairperson) 
Mr Thomas Buchanan 
Mr Alex Easton 
Mr Tommy Gallagher 
Mr Sam Gardiner 
Mrs Carmel Hanna 
Mr John McCallister 
Mrs Claire McGill

Mrs Elizabeth Knipe ) Regulation and Quality Improvement Authority 
Dr David Stewart )

Dr Bharat Patel ) Health Protection Agency

Dr Ray Sheridan ) Royal Devon and Exeter Foundation Trust

The Temporary Chairperson (Ms S Ramsey):

I welcome the representatives of the Regulation and Quality Improvement Authority (RQIA). Please introduce yourselves and give your presentation. There will then be an opportunity for members to ask questions. Thank you for your report, and thank you for coming.

Dr David Stewart (Regulation and Quality Improvement Authority):

Thank you for your welcome. We are very grateful to the Committee for the invitation to come and present the findings of the independent review. I will start by introducing the members of the panel and briefly describe their backgrounds.

Mrs Elizabeth Knipe is a lay reviewer on the Regulation and Quality Improvement Authority panel. We feel that it is very important to have a lay perspective in our reviews. Elizabeth has been a member of several review panels and was a member of the review team throughout this process.

Dr Bharat Patel is a consultant microbiologist from the Health Protection Agency in England. He has a very specific knowledge and awareness of issues concerning clostridium difficile and has worked with several trusts in England that have experienced outbreaks. Dr Ray Sheridan is a consultant in general and geriatric medicine in the Royal Devon and Exeter Foundation Trust. He has been responsible for running a specialist ward for clostridium difficile patients for some time and has brought that perspective to the review.

I will briefly describe the process that we went through to reach our current position. I will then ask Dr Patel to summarise the key findings of the review team. We will be happy to answer members’ questions after that.

In February 2008, the Minister of Health, Social Services and Public Safety asked the RQIA to establish an independent review to examine the circumstances surrounding the outbreak of clostridium difficile in the Northern Health and Social Care Trust and how it was being managed, and to consider the state of preparedness of all trusts in Northern Ireland. The first step that the review team took was to develop quickly a checklist to send to all trusts. A different checklist was sent to the Northern Health and Social Care Trust because an outbreak was already under way in that area. The review team then visited each of the trusts to examine intensively the arrangements within each trust. The outcome of those visits was a report containing recommendations, which was sent to the trust. A summary report was then produced for Northern Ireland, which the Minister presented to the Assembly on 3 June 2008. The report made some 36 recommendations covering a whole series of different actions. If members wish to refer to that report this afternoon, the panel will be happy to answer questions on it.

The particular focus of this afternoon’s session is on the outbreak at the Northern Health and Social Care Trust. At the time the review was established, the outbreak was not under control. It was clear that the review team could not begin to look at events leading up to the outbreak until the outbreak was substantially under control. In July, when the number of cases had fallen, we were asked to start the review, so, over the summer, the review was carried out. As part of the process, we examined a wide range of documentation that the trust, the Department of Health, Social Services and Public Safety, the Northern Health and Social Services Board and the Communicable Disease Surveillance Centre ( Northern Ireland) provided to the review team. In addition, meetings were held, including an intensive meeting with a range of staff in the Northern Health and Social Care Trust.

As members may have seen in the report, the focus of the review was what is called a “root-cause analysis”. The concept behind such an analysis is not to carry out an investigation to assign blame to an individual; rather it is to consider what lessons can be learned from the incident and how those lessons can be applied in the event of any future incidents and to spread that knowledge across the system. We pay tribute to all the staff in the Northern Health and Social Care Trust, the Northern Health and Social Services Board, the Department and other agencies who have willingly given of their time to engage with the review team. The Minister published the review team’s report on 14 October — I understand that members received a copy — and the Minister has accepted the review’s recommendations. I now ask Dr Patel to summarise the key findings of the review team.

Dr Bharat Patel (Health Protection Agency):

The members of the independent review team met a number of staff during several visits to the trusts between February and the end of July. We were impressed by the staff’s dedication and commitment, and their motivation to get to the bottom of the problem and root it out.

I want to explain a little about the outbreak and the ribotype 027 strain of clostridium difficile. That particular strain was first identified in North America; a major outbreak started in Montreal and in Sherbrooke, Quebec, in about 2003. The strain is quite different from others, and it is certainly different from those that we have experienced in the United Kingdom. One aspect of the strain is that it seems to lead to more severe cases and more frequent relapses. Previously, we would have treated a case of clostridium difficile with five days’ worth of antibiotics, and that would have been it; the patient would have felt better, left hospital and recovered. However, the strains that now exist are more potent, and it seems that they are more virulent. An element of mortality is associated with that particular strain.

That is how the picture of clostridium difficile seems to have changed over the past five years, not only on our shores but in Europe and North America. Several factors have been associated with the spread of that infection. It is no ordinary bacterium; it has a form of survival, in that it changes itself into a spore, and those spores are then seeded around the hospital. If one patient is infected, the area of the hospital that that patient is in will become contaminated with the spores.

The spores survive for a long time, and, as they are left behind, they can be transmitted to the next patient who comes along. That is transferred by the faecal–oral route, so the spores will get onto the hands, and the patient will swallow them. Broad-spectrum antibiotics, which are used to save people’s lives, damage the normal flora of the bowel, allowing the spore of the clostridium difficile to sporulate. It germinates and produces toxin A and toxin B, which damage the colon, resulting in diarrhoea.

That is how the disease process works, and we have been aware of that since the 1980s. We also have information on how to control those infections, so it is important to put into context the fact that doctors and nurses were used to a form of clostridium difficile that everyone thought could be controlled, and which could easily be treated, with a drug called metronidazole. We have always done that, but the picture started to change when clostridium difficile was first detected in a patient in Northern Ireland in June 2007. The result was available later on.

The team visited all five trusts, and part of our findings showed a lack of awareness, not of ribotype 027 but of the potential impact of that organism, how it could spread and the severity of the disease that it might cause. The pattern in the Northern Trust was no different. Having appeared in one place, it occurred in two or three hospitals in that trust area in the legacy trust hospitals. The various pressures on the National Health Service (NHS), not only in Northern Ireland but elsewhere, such as the pressure on beds and the transfer of patients between hospitals, led to many outbreaks in that cluster of three hospitals at that time. The time frame of those outbreaks is contained in the report.

It was difficult for people to say that that was all part of the same outbreak, because they did not have the facilities for ribotyping, which is the method by which strains are differentiated. We call the disease ribotype 027. Recognition of the outbreak was delayed until January 2008, and, by then, more cases were being detected and some patients were dying.

We also found that cleanliness was an issue. One of the mainstays of preventing clostridium difficile from being transmitted is to try to keep the areas of the ward clean and spore-free. The more frequently the areas of the hospital are cleaned, the easier it is to get rid of the spores that have been laid down by successive patients who have come into the hospital; that was noticeable both from the nursing staff’s and the patients’ point of view.

There were staffing issues. The trust had started to operate as a unified trust away from the legacy trusts in April 2007, and levels of nursing and cleaning staff, and so forth, needed to be examined. The mergers were taking place in April 2007, but the contracts, the scrutiny of the contracts and how much cleaning was taking place should have been examined a little earlier. However, I can imagine that people who had to manage those systems had other issues to consider in April 2007. All those issues were part of the process.

I have a general comment about the lack of robust monitoring systems. If we do not measure how much infection is occurring, we cannot keep an eye on whether the problem is getting bigger or whether the control of the infection is improving. Therefore, it is important that systems are in place. Those systems are now in place because people are aware of the process, as David described earlier. They are also aware of the importance of monitoring the surveillance of what is happening in the hospital. Monitoring and implementation of antibiotic policies, adherence to the guidelines and the system of routine surveillance of trends have all improved in the past few months since the review team has been examining the situation. We have emphasised the importance of prudent antimicrobial prescribing and control. One of the review team members is a consultant pharmacist in antimicrobial prescribing. Good advice has been received. In January, the cleaning arrangements were probably not robust enough because the problem was not recognised.

It is important to have a system of controlling the infection. One needs to reduce clostridium difficile in the same way that MRSA was reduced. A care-bundle approach was propagated in early February as an important way to control such infections. As I said previously, we had the knowledge to control the infection. However, a crucial aspect in controlling the infection is to implement that knowledge and to ensure that it is working at the front line where the patients are — not just knowing about it in policy and documents.

All five mainstay control measures are documented. The most important of the five measures is to ensure that the patient who has diarrhoea is isolated quickly so that the spores are prevented from spreading. In preventing transmission, we are preventing the contamination that would occur via those spores.

The second mainstay of control is enhancing environmental cleanliness not only in what is seen on surfaces, but also in loos, commodes, bedpans, patient-contact areas and handrails. People must be absolutely meticulous about cleaning those areas because that is where the contact occurs and where the next patient acquires the spores. Cleaning is very important.

Another measure is prudent antimicrobial prescribing, which is ensuring that the people who prescribe drugs have the knowledge and understand that antibiotics can save lives but that they can also do harm, because they affect and destroy the normal bowel flora that we all carry — the good bugs — and allow the spores to sporulate inside the gut. That is how the toxins are produced. Prudent antimicrobial prescribing is an important mainstay.

The availability of protective equipment for nursing staff and healthcare workers is crucial. The final measure to be considered is the importance of hand hygiene. Bugs and spores are carried on hands, and that must be evaluated also. It is also imperative to ensure that people are compliant with the regulations and that they wash their hands when entering a ward.

The Minister has accepted the 36 recommendations that we made in the interim report and the further 17 recommendations in the August 2008 report. The implementation of those recommendations will go a long way to ensuring that hospitals in Northern Ireland have low rates of clostridium difficile. Low rates mean that fewer patients will be affected by the bug, and fewer will, ultimately, die from the infection.

It is the responsibility of the chief executives and managers of thetrusts to implement those measures, and it is up to them to ensure that all the systems that we have described are implemented on the front line.

The Temporary Chairperson:

Thank you for your presentation. It is useful to have independent people such as you making the recommendations, and I am pleased that the Minister has accepted them in full. The recommendations will be implemented across all hospitals.

The next step will be the public inquiry for which the Committee called. However, some family members are still asking whether the public inquiry will affect all hospitals and not only those within the remit of the Northern Trust. That must be considered.

The situation required a common-sense approach. Were you disappointed that, in a layperson’s terms, the common-sense approach failed. Were you disappointed about the lack of awareness, the cleaning arrangements and the lack of knowledge about the seriousness of diarrhoea? I know that patients with diarrhoea are put in isolation. I do not want to criticise staff, but were you disappointed about the lack of awareness — especially in respect of hospital cleanliness? Should our hospitals be deep cleaned so that we can build on the good work that has been done?

Dr Patel:

It is important to recognise that healthcare workers try their best, sometimes under difficult circumstances and a lot of pressure. At the first meeting that I had with the RQIA medical director and the chief executive in the RQIA rooms, we set our agenda. The first item was patient safety. Subsequently, we considered why we were in the position that we were in and what we needed to do. We discussed what was happening in the Northern Trust, and, subsequently, we considered how we could protect the affected hospital, the patients and the local community from the occurrence of further infections. That is why we sought the reassurance to ensure that the control measures were there.

The second discussion was wider. We knew how to control the outbreak, but we had to consider how we could prevent the same from happening in the other four trusts. At that stage, the questionnaire, which had been tried and tested, was converted to a Northern Ireland format. It had to be converted because different terminology is used here. For instance, we do not have a director of infection, prevention and control (DIPC). We had to convert it so that people would understand. We issued the self-administered questionnaire, and it had to be returned within two weeks so that the protection of those hospitals and their patients from the risk of clostridium difficile could be ensured.

It was clear at the outset that the infection had not spread. Those hospitals had the normal strains of clostridium difficile but not ribotype 027. We also recommended that a sample of strains in the four trusts be sent for typing in order to delineate whether ribotype 027 existed in those hospitals. I am pleased to report that ribotype 027 was not present in those hospitals when that sample was taken.

A Northern Ireland-wide approach was taken in the first few months. We visited those trusts to ensure that they had sufficient robustness to control ribotype 027 if it entered their hospitals. The review panel used its expertise to advise on the appropriate systems to ensure that patients were protected and that patient safety was prioritised. That fact was borne out by the people whom we interviewed in those hospitals. The group contained about 20 people — from the chairman of the trust, or a board member if the chairman was not present, to the chief executive — who ensured that the measures that will protect the population were being taken seriously.

De-cluttering and cleaning of the dusty nooks and crannies where the spores lie is important. The value of deep cleaning is that it is a systematic approach that ensures that there is nowhere for those spores to be. Infections can be reduced quite significantly, but they cannot be totally eradicated. Some 3% of the adult population carries the spore; indeed, there may be people at this table who have the spore in their tummy. It is only when certain circumstances arise prior to the antibiotics being given that carriers of the spore will get the disease.

I will ask my colleague Ray to share his experience and to reiterate the importance of de-cluttering, dusting and deep cleaning.

Dr Ray Sheridan (Royal Devon and Exeter Foundation Trust):

We have just undergone a rolling deep clean of our entire hospital. Each ward was completely emptied of patients; every piece of paper that could be carrying dust was put in the bin; each ward was washed and repainted; the unit was sealed and a hydrogen-peroxide machine was used to kill the spores; and then patients were moved back into their respective wards.

It was an interesting process, because the rates of clostridium difficile tumbled as the deep clean rolled through the hospital. The infection melted away in the units that are associated with higher rates of clostridium difficile, such as those wards containing elderly people. Deep cleaning should be a rolling process. Nursing teams stayed on their respective ward as part of the cleaning process, and it became a team-building exercise. Nurses regained ownership of their respective wards, and woe betide anyone who came in and messed it up when it reopened. People took a real pride in their wards again, and that was an unexpected by-product of the rolling deep clean. Deep cleaning can also be useful as part of a wider process.

However, it is expensive and a massive logistical operation. Furthermore, beds are lost for the time that wards are completely empty. There are financial implications of deep cleaning, but that money may be saved by having lower rates of clostridium difficile in the future. Deep cleaning has benefits, but it needs to be a rolling process, and it is not a substitute for an ongoing and regular cleaning process.

The Temporary Chairperson:

Some Committee members made a formal visit to the maternity unit in the Royal Victoria Hospitalthis morning. I noticed that there were industrial domestic waste bins on the corridors, which struck me as problematic because of the spread of infection.

Mr Gallagher:

I thank the witnesses for their presentation and interesting comments.

It is startling to look back at the lack of awareness among staff at what Dr Patel described as the severity of this strain of clostridium difficile. Who was responsible for informing the trust once the outbreak was recognised — the RQIA or the Department? Which body would have notified the other trusts? Was that notification just a simple notification that clostridium difficile ribotype 027 existed? Was there anything else in the communication — for example, an instruction to do a, b and c as a consequence? I want to know whether whoever alerted the other trusts knew that staff had such limited understanding of the impact of this strain of clostridium difficile.

Dr Stewart:

I can answer in general terms; after which I will ask my colleagues to contribute.

There were two large outbreaks of clostridium difficile in England, of which members might be aware. The Department issued guidance to the system in April 2007, in the year before the outbreak was declared. Therefore, just after the new trusts were formed, specific guidance on clostridium difficile was issued. It highlighted the importance of the care-bundle approach, which Bharat described. It specified the five issues that needed to be addressed. That was circulated to all the trusts in the Province.

The review team found that there was a general lack of awareness of the severity of ribotype 027. I will ask Ray and Bharat for their views. That was not exclusive to Northern Ireland; outbreaks were occurring in other countries. As Bharat described, people were thinking about clostridium difficile in a way that they had not done previously. The Northern Trust, for example, had had two occasions in the past — in 1999 and 2003 — when the number of cases of clostridium difficile had risen. It was able to put into effect measures to control the infection. When the outbreak was declared by the trust in January 2008, steps were taken by the Department to make the rest of the system aware. There was no general awareness, however, that we were dealing with something different. There was an awareness that the strain had caused outbreaks elsewhere; however, that message had not been communicated through the system.

Dr Sheridan:

That is a global healthcare problem. At the same time as the Northern Trust was clobbered, most hospitals in Great Britain and across western Europe were probably unaware of the severity of the 027 strain, unless that was their specific area of expertise. An orthopaedic surgeon would not have been sufficiently aware of it in any country in western Europe.

Mr Gallagher:

Was anyone in the Department sufficiently aware of the danger?

Dr Stewart:

The Department had an awareness of the ribotype. Before the outbreak, only a small number of cases were typed; however, that practice was not unique to Northern Ireland. As Bharat mentioned, ribotype 027 was first detected after a patient became ill in June 2007. We must remember that staff at the Northern Health and Social Care Trust realised that that patient was more severely ill than previous patients with similar symptoms, and they took action to get the strain ribotyped. However, the results did not come back until September 2007. With hindsight, people were becoming ill, and there were some small outbreaks, but the ribotyping information was not available to diagnose those.

One of the report’s recommendations is that Northern Ireland should a have more formal system in place for examining the risks of different organisms. However, most people would argue that one would need to know quite a bit about the system to be able to identify the differences in ribotype strains. Bharat may have a different opinion.

Dr Patel:

It would be impractical to ask a hospital to ribotype every single case. Countries do not do that, because the number of samples would overwhelm the laboratory and the system. However, from time to time, a picture of when and where outbreaks occur must be created. In February 2008, the Chief Medical Officer asked for public reporting of quarterly surveillance reports on clostridium difficile. Northern Ireland will be one of the first countries to have 25% of its clostridium difficile cases typed.

The system is in place, and samples have been sent to the reference laboratory in England to assess the spectrum of the disease. That will include ribotype 001, which is the old strain of clostridium difficile, as well as other cases. A picture is being built of what strains already exist. That has been happening since February, and it is a very good thing. Before that, 60 samples were sent to be typed, and none of them had the 027 strain. We should be reassured by the fact that someone had the initiative to take 60 samples from Northern Ireland to have them typed. Given that the 027 strain was not typed then, we can actually try to pinpoint when it was introduced. Clearly the strain did not exist here; rather, it was introduced. However, we cannot define the exact period at which it might have entered the system, because more than 200 ribotypes of clostridium difficile exist. Ribotype 027 entered the system from somewhere, but it would be inappropriate and too costly for us or someone else to try to pin down when exactly that happened. The mainstay should be to develop control measures and to drive down instances of clostridium difficile so that there is zero tolerance to clostridium difficile across the five trusts in the Province.

Dr Sheridan:

One of the most valuable lessons from this exercise has been the development of a system akin to a weather-forecasting system. What will be the next big problem? What disease is emerging and what is spreading from Europe, the United States or England? One recommendation is to have that system in place, because it had not been in place anywhere else. That is a wider learning point for other infections.

Mr Easton:

Thank you for your presentation; it is fascinating stuff. How long can spores survive in the open, and are there cleaning agents to kill them?

Have you made any recommendations to restrict visiting hours? I liked your idea about wards being deep cleaned; will that happen in each ward annually?

I visited my mother-in-law in the Ulster Hospital a couple of weeks ago. When I entered the ward that she was on, there was a bottle of alcohol gel for visitors to use on their hands. Am I correct that that does not kill clostridium difficile? It also struck me that nobody enforces the use of the alcohol gel. Have you thought about having nursing stations at the entrances to wards and tasking someone to ensure that visitors use the alcohol gel?

Dr Sheridan:

The spores can last for years; they are very resistant, so they need to be kept on top of. Bacteria tend to die very quickly, but spores can last for a long time. There are specific cleaning agents, which have been discussed in the depths of the report. There are certain cleaning agents that are better than others. The frequency of deep cleaning will depend on the unit — a busier unit with a high turnover of high-risk patients requires deep cleaning more often than one with a lower risk. There is no definite research that states how frequently a ward should be deep cleaned, but at least twice a year would be sensible.

Mr Easton:

Twice a year for every ward would be good.

Dr Sheridan:

That has to be interpreted differently for different units.

The alcohol gel does not kill clostridium difficile, but it kills lots of other bugs like MRSA. The introduction of alcohol gel has been a major contributor in the fight against MRSA. The alcohol gel has been removed from our isolation wards to force people to wash their hands. The alcohol gel is a very useful way of getting people to think about their hands, but you are right — hand washing needs to be brought back.

How can such measures be enforced on visitors? We look at the situation as an open-culture challenge; we encourage patients to ask healthcare staff if they have washed their hands before they allow themselves to be touched. That is difficult for some patients to do, and we want them to feel comfortable doing that, so we have put posters up encouraging it. We also encourage everyone in the ward to challenge one another, from the receptionist to the cleaner to the consultant. Once that is done in a mature organisation, everyone is comfortable, but it requires a culture change.

Most units have imposed stricter visiting hours. As with deep cleaning, approaches to visiting hours will vary; a paediatric unit will have a different approach to visiting mums than an adult unit. More restrictive visiting hours and a limit on the number of people allowed at a patient’s bedside are almost universal in our trust.

Mr Easton:

What do you think about having nursing stations at the entrance to units so that visitors are forced to wash their hands? I like that idea. [Laughter.]

 Dr Sheridan:

I can see the attraction of that idea, but its unforeseen consequences would have to be risk managed. Often, nursing stations are positioned so that nurses can keep an eye on patients — nurses must be able to see their patients in case they fall and to monitor their night-time health. The most vulnerable patients are nearer the nursing stations so that they can be monitored. Perhaps having a receptionist by the entrance to a ward could be a solution. In some wards, visitors have to be buzzed in.

Mr Easton:

Is that something that you are considering?

Dr Patel:

As Ray suggested, one must be pragmatic. Two of the themes in our report are behavioural and cultural changes. If Kieran were here, he would mention some of the cultural perceptions of antibiotics. Kieran is our antibiotic tsar —

The Temporary Chairperson:

Kieran Deeny or your Kieran?

Dr Patel:

Dr Kieran Hand from our team.

The Temporary Chairperson:

I thought you meant our Kieran.

Dr Patel:

He is an antibiotic champion and knows how these things work. He has examined the European data, which show that Northern Ireland has one of the higher levels of patients demanding antibiotics from general practitioners and elsewhere. Again, that is a cultural and behavioural issue.

The visiting policy that you have suggested was introduced, which we have discussed with staff. However, one must consider what will be tolerated by patients’ relatives. One cannot forget a patient’s need to have visitors. Patients being able to see their loved ones when they want to affects them socially and psychologically. One could take a visiting policy to extremes and insist that visitors can stay only for an hour, but if patients are 80 years of age or perhaps older, they may want their relatives and friends to come and visit. There must be a balanced and pragmatic approach that considers what is realistic and what is the right thing to do, and also whether it can be done safely. Each hospital will have to consider that in its own way. Clearly, restricting visiting is not appropriate for a maternity or paediatric ward, so one has to take a pragmatic approach.

Hospitals are dynamic systems — it is not as though things stop; there is constant transition. There may be 30 to 100 patients processed through accident and emergency, and 30 patients may be admitted every day; one of the hospitals that we visited admitted 50 patients in one day. One must consider the dynamics of that, and the fact that someone who has been admitted will need to have their clothes brought in, and so forth. The hospital must be a functional place, and we have to be mindful of that. We cannot impose a fixed regime to stop some of those things happening. We have to put ourselves in the position of the patient and ask what we would want if we were in hospital. Then one starts to get the answers.

Mrs Hanna:

Good afternoon; you are all very welcome. We are all relieved that the outbreak is over and that the focus now is on trying to ensure that it does not happen again. What is the role of the RQIA, now that that outbreak is over? Does it have a monitoring role to ensure that the recommendations are implemented? You said that ribotyping is unfeasible; is there any kind of screening that can be done in the middle of an outbreak, when patients — particularly older patients — may arrive at hospital presenting with diarrhoea and may need to be hospitalised; they cannot be sent home.

Public education is an issue. I accept what you are saying about the need for a balanced approach to visiting; that has to be the case. However, given that a certain percentage of the population carries the virus, the public must be made aware that hospitals are places for sick people and that, when they visit, they must be very aware of hand hygiene, and so forth. Education on those matters must be improved. Although it is not one of the main recommendations, I know that the issue has been discussed. It is important to change that culture and to make the wider public aware that they also have some responsibility.

Dr Stewart:

I will take the first question and ask Bharat to take the second question, and perhaps Elizabeth can deal with the issue about the wider public from a lay perspective, because the review team met some people who had been affected by the outbreak. In relation to the role of the RQIA, the review is currently at the stage of examining the implementation of changing the regional culture strategy, but that process is more to inform processes within the Department, and we will share information rather than create another report. The review team will not have a formal role, but members will recall that we have also been asked to take a role in rolling out a programme of independent hygiene inspections.

During the first round of inspections earlier this year, we made unannounced visits to six hospitals across the Province. A team went into those hospitals to study the situation on the ground. Through the Department, the Minister has now asked us to make that part of our mainstream work. We will begin an ongoing programme of unannounced hygiene inspections from January 2009.

We are discussing whether we will expand beyond the environmental hygiene role and consider some of the infection-control arrangements during those visits. That will be a method of determining the situation on the ground. We hope to expand that role beyond acute hospitals and consider mental-health and learning-disability hospitals, and large community facilities. In the case of this independent review, however, the role of the review team will now cease.

From an RQIA perspective, we have been extremely grateful to members of the independent review team. They were very generous and have devoted a great deal of time to Northern Ireland. About three or four weeks ago, a group of people from a trust visited Ray’s unit to experience its arrangements. Bharat visited a trust about a fortnight ago and met a range of staff. That is outside the arrangements that those panel members had with the review, so they have given a great deal of their time to the process.

Dr Patel:

Mrs Hanna asked about ribotyping —

Mrs Hanna:

Or any type of screening.

Dr Patel:

A system is in place for regular surveillance so that Northern Ireland will have some trend data on changes and patterns of the ribotypes that occur and exist. That is currently taking place. Over the past two years, the Health Protection Agency established the Clostridium Difficile Ribotyping Network for England (CDRNE), which consists of five laboratories that carry out the ribotyping service. Northern Ireland is served by the Leeds system and is part of the CDRNE network.

Any hospital that experiences an increasing number or a cluster of cases, or declares an outbreak, is able to access the CDRNE network through the Health Protection Agency so that the typing can occur. It is currently a much better and robust system. Discussions are already under way between the Leeds laboratory and the network to establish whether the ribotyping service could be established in Northern Ireland. Finances and resources are being discussed to establish whether Northern Ireland could join the English network and share the systems, information and knowledge, because it is important to share those.

Mrs Hanna:

That is good, because my perception during the outbreak was that there was more of that taking place across the water than there was here.

Dr Patel:

The scales have tipped.

Mrs Elizabeth Knipe (Regulation and Quality Improvement Authority):

You also asked about educating the public about hand cleaning. When we visited hospitals, we talked to patients in the wards as well as the people who had contracted clostridium difficile who came to see us. The feeling was that the public was reasonably well aware and was reasonably good at using the hand gels — sometimes better than the staff.

Therefore, public awareness about the importance of using the hand gel exists, but it could be built on. We sometimes found that the gel was not in a very prominent position and may not have been obvious to people going into hospitals. Awareness of the importance of hand hygiene is increasing, although the educational aspect must be followed up on.

Dr Patel:

During each of our visits to the five trusts, the team split into groups of two or three and visited three or four wards. We spoke to patients who were not part of the outbreak but had suffered clostridium difficile, and we listened to their perspective. As I mentioned earlier, the review team also spoke to the staff, down to the level of the cleaners; we spoke to them about their job and how they felt about the situation. As Ray said, it is important that people feel valued and part of the team. The cleaners are not simply cleaners; they are part of the healthcare team that protects the patients from contracting the infection. That psyche must be built into the system so that all staff see themselves as part of the team that looks after those patients. Liz, I hope that you agree with that?

Mrs Knipe:

I agree absolutely.

Mr Buchanan:

I welcome the report and its recommendations; I sincerely hope that the recommendations will be implemented across the boards as soon as is practicable. It appears that there is a two-pronged approach to dealing with the problem, which involves the antibiotic aspect and the issue of cleanliness.

There is no getting away from the fact that we live in an antibiotic culture, where many people feel that they are not doing well unless they are taking antibiotics. That must be tackled. I welcome the recommendation that each trust board should promote sound antibiotic stewardship. The culture of taking antibiotics must be stamped out. I am not a fan of either antibiotics or medication of any kind, but that is beside the point because they are sometimes necessary. The antibiotic stewardship is being promoted in the trusts and in the hospitals, but what is being done about GPs prescribing antibiotics to patients?

It appears that there has been a failure on the part of the chief executives or the chairs of the trusts to ensure that a thorough cleaning programme was being carried out. Perhaps such programmes were not carried out. The recommendations state that visits by the chairs and chief executives to hospitals should focus on infection prevention and control. What training have those people been given that will help them to know, when they visit the hospitals, that those issues are being controlled in the way that they should be?

I have a difficulty with the fact that much of the cleaning in hospitals is now contracted out rather than being managed in-house. Contractors bidding to take on the cleaning of hospitals in a trust area will cut their prices to the lowest possible rate in order to secure that contract. Therefore, I want to know how those contractors are regulated to ensure that they are, for example, using the right materials and the correct cleaning liquids, and are doing their job in the hospitals to perfection. Given that the contractors will be charging low rates, how can we know that their staff are doing a proper job and are cleaning all the areas that were mentioned — for example, handrails — in order to help to keep the disease at bay?

I am concerned that responsibility for hospital cleaning has moved from in-house to contract. In many cases, that results in the cleaning not being as up to scratch as it would have been if it had remained in-house.

Dr Patel:

You raised the issue of restrictions on the antibiotics that can be prescribed by GPs. We had an opportunity to meet the Northern Health and Social Services Board, and we also met the public-health director on that board who assisted the Northern Trust in part of the activities to control that.

We discussed, and we made a recommendation on, communication and dialogue between the hospital and primary care in the community. That dialogue takes the form of a discharge letter, in which the GPs, nursing homes and care homes are told about the care of the patient who has recovered from clostridium difficile and then been discharged, either to home or to a care home. The GP must be aware that the patient has had clostridium difficile so that, if the patient gets another infection, the GP can be cautious and prudent before another course of antibiotics may be prescribed. Prescribing antibiotics to a patient who has had clostridium difficile may be the road to relapse.

We also talked about a strategic approach between the hospital and the community on prudent antimicrobial prescribing. We make a differentiation between the hospital and the community, but, given that patients come in and out of hospital, the health economy is the same. Everyone, not only the hospitals, must work at prudent antimicrobial prescribing. The community and those in primary care must do that. Through the antimicrobial resistance action plan (AMRAP), a strategic approach is taken across Northern Ireland. Part of that plan considers all the systems for antimicrobial prescribing.

I am sure that Ray will address the issue of walkabouts. If one walks up and down a corridor in a hospital, one will notice things that need to be fixed; such problems shine out. Cleaning supervisors do not need to be trained to do that, as they are already trained to pick up on those issues.

Sisters who work on wards are trained to notice if something is not right. They must have the courage to say that they will not tolerate something and that they want it fixed. The culture and behaviour, to which I referred earlier, must be changed so that people do not walk by and ignore the faults, but so that they fix them. Systems must be introduced to deal with that.

The person who does the walkabout may be the chief executive, the chairman of the board or one of the board members, and that person will recognise those issues. In another trust, the chief executive did a walkabout that revealed that something was wrong with the seat or the door in a loo. Feedback from nurses shows that that was fixed immediately. The system needs the right people to be involved in the decision-making process to ensure that a problem is fixed on the day that it is identified. That culture must be engendered.

Dr Sheridan:

Pharmacists with a special interest in antibiotics monitor their use in the community and in hospitals. There is good evidence to suggest that that works; those pharmacists can engage with clinicians and change prescribing habits, but a monitoring system is needed. That system is better in general practice than it is in hospitals. The trust will know the antibiotic prescribing habits of any individual general practice, and it will be able to spot the ones that are outliers in the use of certain antibiotics. We found that antibiotic pharmacists are an effective way to educate and effect change. I would encourage such a system.

We visited one hospital in which the cleaning staff had ownership of the cleaning issues. While we were present, there was a small cluster of clostridium difficile. The cleaning staff organised, putting their more senior cleaners into that area rather than temporary staff. Cleaning staff are beginning to take ownership of that sort of problem.

Dr Stewart:

That has a bearing on Elizabeth’s point. Cleaners, regardless of how they are funded, have to be made to feel part of the team. Cleaning is becoming a technical business. Different cleaning agents are needed for different types of surface, and different types of cleaning are needed for different hospital arrangements. Cleaning staff have to be well trained; they are vital to the reduction of infection.

The Temporary Chairperson:

Perhaps their wages should be reviewed.

Mrs McGill:

The witnesses are most welcome; I thank them for their briefing, and I commend them for their work on clostridium difficile.

I also want to talk about cleanliness. I agree with much of what was said by Mr Buchanan, and I will not prolong the discussion. Years ago, the perception was that a hospital was the cleanest place that people could be. What has happened? Why did that change? It changed, and we are paying the price for it.

The Temporary Chairperson:

They got rid of matrons.

Mrs McGill:

That is all that I will say on the matter.

I come from the Western Health and Social Care Trust area, and the hospitals in my area are Altnagelvin Area Hospital, Tyrone County Hospital and the Erne Hospital. When the Committee visited the Erne Hospital, I spoke about that issue with one of the medics who met us. The infection nurse spoke to me, which I appreciated.

Did you find out, when you visited the trusts, the single-room capacity of Altnagelvin, Tyrone County and the Erne hospitals? Is there a record somewhere? Is it documented and with the Department? It would be valuable for the Committee to have sight of that information.

My second point relates to clinical champions, who are referred to in recommendation 3 of the May 2008 report. However, a note after recommendation 24 states:

“The Review Team recognises that this will not be achieved across Northern Ireland until there is an enhancement of relevant staffing levels.”

I wonder what the situation is in relation to that.

I raised the issue of nurses with the Minister in the Assembly some months ago; Mr Easton raised it in Committee not long ago. How will a cut in staffing be managed? Will nurses have to do a great deal of extra work? When Committee members visited the Erne Hospital, we met a nurse who had a lot of additional work to do. I want to know how the practicalities of that will work out.

Dr Stewart:

The review team examined the level of isolation capacity when it met representatives from each trust. The Committee should hear from Ray, who visited Tyrone County Hospital, and Bharat, who visited Altnagelvin Area Hospital.

After the first report, I understand that there was a departmental request for all trusts to report on what they saw as their particular areas of difficulty with isolation capacity. It is fair to say that the situation is variable across Northern Ireland, and it can be variable even within each hospital. Ray visited Tyrone County Hospital, where there was a limited amount of side-room capacity, and Bharat visited the Mater Infirmorum Hospital, which had a superb range of facilities and side rooms available. It is a very variable picture. However, I understand — and I will have to check with the Department — that there was a specific exercise for people to review their estate, and that was carried out after the first report.

Dr Sheridan:

From memory, Tyrone County Hospital was about to go through a rebuild programme — or wanted to — and those issues would have been part of the rebuild plans. I stand to be corrected if I have mixed up the hospitals.

Mrs McGill:

Is there provision in Tyrone Country Hospital for —

Dr Sheridan:

Tyrone County Hospital did not have sufficient side-room capacity. Side rooms are a fantastic idea, they sound great and, if I were going into hospital for an operation, I would want a side room. However, the experience of patients in side rooms is not what one might imagine. Many patients who go into side rooms ask to be allowed to come out onto the open wards because they feel isolated and locked away. It is a bit like being in a prison cell. There is a lot of time during the day to fill. A patient in an open bay — which is something that we thought that we would move away from — sees a lot of other activity and coming and going. A nurse can easily keep an eye on six patients: when she pops in to see the patient in the corner, she can keep an eye on the other patients as she goes past.

Although I strongly encourage that we should move to a higher percentage of side-room capacity, one would need to build in the fact that that may not always be the answer. Some of the patients may not want a side room.

Mrs McGill:

Recommendation 6 of the May 2008 report states:

“Each Trust should review its single room capacity … for the prompt isolation of patients with symptoms of Clostridiumdifficile.”

I do not have a view on which is better. You are the experts. However, I wanted to know the side-room capacity in my area and in Tyrone County Hospital.

Dr Patel:

The issue of side-room capacity has been discussed with each trust. Clearly, with the legacy trusts and with the fabric of some of the buildings, there is a mixed economy. There are some hospitals, such the Mater Infirmorum Hospital, where each ward has seven side rooms. That was a good distribution, and the nurses liked to work in that environment. However, those are individual matters for individual trusts to examine.

If a hospital has 30 cases of clostridium difficile a month, we would suggest that side rooms were available. However, that hospital might wish to use an isolation ward to bring all those cases together so that they can be managed better by experts such as Ray and other colleagues in Northern Ireland. The patients like that situation because they are being looked after better. There are patient-care pathways so that the patients can be looked after expertly by doctors who want to save their lives. The isolation ward comes first: if there were 30 cases a month, a hospital would be better off taking an isolation-ward solution because it would overwhelm its side-room capacity.

If the incidence levels reduced, the hospital might be expected to use its side rooms more efficiently — in the capacity that I explained earlier; for isolation — to prevent transmission and environmental contamination. Each trust must, therefore, examine its own capacity and its requirements for the prevention of MRSA, clostridium difficile and extended-spectrum beta-lactamases (ESBLs) , which is another pathogen. Each trust must consider its own situation. Those reviews and audits are being carried out by other hospitals. Therefore, templates are available that can be used to determine necessary capacity. It would be imprudent for us to say that the appropriate solution for each individual trust is a 30% ratio of side rooms to general-ward beds. We cannot say that.

The direction of modern medicine is towards increasing side-room capacity. We have heard of hospitals that have 100% side-room capacity. PFIs are being suggested for provision of 100% side-room capacity. That must be considered from a nursing point of view; can patients be looked after adequately? Will a patient be seen twice a day? What happens in those rooms? How many staff are needed to man a 400-bed hospital with 400 side rooms? No one has thought through those logistical problems, and they must be considered. The question that the member is asking is whether local trusts have enough side rooms. Trust personnel will know, because when their available side rooms are running out, they cannot isolate people who need to be isolated. That means that more side rooms are needed.

We have spoken specifically to the chief executives of each trust and recommended to them that they must review side-room capacity, so that, when their trust receives its capital funds, some of that money can be invested in building costs, the various areas where side rooms might be needed can be examined and those side rooms can be built. There will be areas, such as wards that provide healthcare to elderly people, where they will discover that there is insufficient side-room capacity and that, therefore, space must be converted into more side rooms. The specific recommendation has been made verbally and generally to trusts that they must review their side-room capacity in order to take that on board.

You mentioned staffing levels. We have made recommendations to the Minister and to each individual trust. Some trusts have only one microbiologist as their expert. As you mentioned, much advice must be given on the many jobs that need to be done. In a modern healthcare facility, it is insufficient to have one microbiologist to examine antibiotic prescribing; to provide training; to carry out laboratory work; to give advice; and to do ward rounds and other such activities. We recommend that that provision be increased and that microbiology should be part of a network, so that cross-cover arrangements can be made among hospitals and so that cover and advice are available. Several recommendations deal with those issues.

One common infection-control policy with minor variations would suffice for the five trusts and for all Northern Ireland, which has a population of almost two million people. One policy on network, cleaning, and so forth, would also suffice. The issue must, therefore, be considered as a whole economy in order to determine how to bring all of that together.

Another point about staffing is that there is a shortage of antimicrobial pharmacists. We recommend that their pay scales be reviewed so that the right type of person is attracted to the job and is paid the right kind of money. That will mean that Northern Ireland keeps its antimicrobial pharmacists’ expertise. A similar approach must be taken towards infection-control nurses.

The staff on the wards, the trust and the chief executive would rely on those experts to give them advice on what needs to happen. Staffing issues need to be dealt with in that way, as does the ward staff issue that was previously raised. Otherwise, there is no one to carry out ward rounds, to interact with colleagues in order to implement changes in practice or to flag up the need for an audit, and to heed the results of that audit. If there are no experts on the staff, there is no capacity to do those things.

The last word is on clinical champions, which are a good thing. The report mentions leadership, and we have discussed the issue of chief executives and members of boards; leadership is important. If there are leaders who say the right things and assert that certain matters will not be tolerated, they will drive change. Earlier, Mr Easton mentioned the need to change culture and behaviour; that can be done only if there are leaders. If the clinical champions do it, the rest will follow. Clinical champions will lead and influence, and others will line up behind them. That is the way in which changes can be made to the culture and behaviour of an entire system and organisation. If one considers some really good airlines or shops, they will have systems in place in order to run efficiently and smoothly; they do not have too many disasters. We want to ingrain those kinds of systems in the five trusts. I have said too much.

Mrs McGill:

Each trust should identify a clinical champion at consultant level; has that been done? Is there a record of that?

Dr Patel:

The independent review team has made recommendations. It has provided guidance and policy on the control of clostridium difficile. However, those are just pieces of paper; the question is whether the recommendations are followed on the front line. Whose responsibility is it to ensure that those recommendations are heeded at that level? Although the Department was quick off the mark, having issued guidance and a good practice guide in April 2007, the question is how that is then embedded in practice. Who ensures that the guidance is being implemented in a trust?

The review team has worked hard at this issue; between the interim report and the final report we have made a total of 53 recommendations, and some of those recommendations have already been implemented — I think that the infection-control policy was launched last week. Various other recommendations are in the process of implementation. The process is moving, but I do not think that it is the responsibility of the review team to check that those recommendations are implemented.

Mr Gardiner:

Thank you very much for your presentation. It was very enlightening but also frightening. Some Committee members, including me, visited the Royal Victoria Hospital this morning, and we ensured that we used the hand-washing gel every time we went through a door. However, we were not aware that it did not protect us from clostridium difficile. The public are ignorant to the fact that precautions must be taken; I have not seen any television advertisements requesting that people should visit hospitals only to see close relatives, and not just for courtesy visits, because they may carry the infection into the hospital.

I know of a case in Craigavon Area Hospital, which I have mentioned at previous meetings, of a lady who died with clostridium difficile, but it was not mentioned on her death certificate. A member of her family knew and alerted the undertakers, because undertakers have to wear special protective clothing when dealing with the body. That is negligence.

Members of the Health Committee have a duty not to visit hospitals during an outbreak of clostridium difficile because we are, perhaps, as guilty as the public about making unnecessary visits. We saw for ourselves, however, that the Royal Victoria Hospital is making great efforts to get on top of the situation.

We must get the message out to the public. I hope that money is spent on buying a few advertising slots on television in order to warn the public not to visit hospitals unnecessarily. We have to get that across to save lives at the end of the day.

The Temporary Chairperson:

Most Committee members took that advice today and did not visit the hospital.

Dr Patel:

The Chief Medical Officer has already issued guidance on death certification and how forms are supposed to be completed. Measures have already been taken with respect to reporting deaths related to healthcare-associated infections. How effective that guidance is and how far staff comply with it are separate issues.

We have talked about practice, public perceptions and dissemination of information to the public. We have addressed those matters at trust level, detailing who should tell the patient that he or she has hospital-acquired clostridium difficile infection. That has been brought to the attention of all the trusts. We are also asking whether trusts have sufficient leaflets for patients. Signage has been put up to make healthcare staff aware of the issues. It is happening, and we have seen evidence of it. However, it takes a while to make progress, but the process is under way.

Mr Gardiner:

The pace of change is too slow, however.

Dr Patel:

It is slow, and we need to move faster. It is everyone’s job to do so, not only that of the Department of Health, Social Services and Public Safety, the board or healthcare workers. It is everyone’s job to raise awareness of healthcare-associated infections.

We have a great surveillance unit in Northern Ireland, and I had the privilege of visiting it a fortnight ago to investigate the treatment of surgical site infections. It does tremendous work, and it has gathered good trend data. Trends in surgical site infections reflect the increased care that has been taken to prevent infection from occurring on wounds after an operation. There are some good assets in Northern Ireland, and they work as part of a long process to put everything together to increase patient safety, which is the most important objective.

The use of alcohol gel and hand washing present us with a dilemma. Two years ago, we used alcohol gel to do that, and then clostridium difficile arrived. Spores of the infection will remain unaffected by alcohol on the hands. One must physically wash one’s hands to get rid of them. That raises practical issues: if nurses and healthcare workers washed their hands every time that they saw patients, the occupational health department of that hospital would have a problem. The skin of occupational health workers would be cracked, and MRSA would go onto the cracked skin. That is why gel is used.

It is important to know when to use gel and when to wash hands. When hands are soiled, or a worker has attended someone with diarrhoea, hands must be washed; when he or she takes a patient’s blood pressure, for example, the alcohol gel should be used. Knowledge about the issue increases as research proceeds and evidence is gathered. We are all on a learning curve, and we are trying to learn faster, but there is only so much that can be done at a time. Northern Ireland has achieved much in the nine months that I have been involved in the process. The trusts have learned a lot. Everyone — including patients and relatives — must improve.

Mr Gardiner:

You must reflect on the fact that members of the public who visit hospitals are not seeing the big picture.

The Temporary Chairperson:

Thank you for your presentation; it was interesting, and it raised several issues. Dr Patel gave the example of how airlines or shops have systems in place to ensure that they run smoothly. It strikes me that there seems to be a lack of accountability in the Health Service — where does the buck stop? Were I the chief executive of a hotel where the cleanliness was below par, I am sure that I would not remain in that position for long.

I agree that the idea of having a cleanliness champion is worthwhile. The Minister has accepted the recommendations in the report; it is the Committee’s responsibility to keep those under review. Are members content that the Committee should write to the Minister to ask for an update and a progress report?

Members indicated assent.

The Temporary Chairperson:

Once again, I thank the witnesses for their presentation and for giving up their time to be a part of the review — it is much appreciated.

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