Coming Clean

31 August 2005 (Last Updated August 31st, 2005 18:30)

Nosocomial infections and general hygiene in hospitals are issues that are capturing attention around the world. Some protagonists, intent on improving things, speak to James Leavey about what is being done and where to go from here.

The growing problem of healthcare associated infection will be addressed by the World Alliance for Patient Safety when it launches the Global Patient Safety Challenge programme at the WHO's headquarters in Geneva on 13 October. The programme's theme is Clean Care is Safer Care, and an advanced draft of the WHO guidelines on hand hygiene in healthcare will be available on the day.

One of the launch's keynote speakers will be Professor Didier Pittet, who is leading the Global Patient Safety Challenge and is director of the infection control programme at the University of Geneva hospitals.

"The Global Challenge will help strengthen the commitment of interested member states to the critical role of hand hygiene in controlling the spread of healthcare-associated infection and multi-resistant pathogens," says Pittet. "Ministers of health and major associations of healthcare professionals from around the world have been invited to formally pledge to tackle healthcare-associated infection, to give priority to hand hygiene in healthcare, and to share results and learning internationally."

"At present, the average rate of hospital admissions complicated by nosocomial infections or by healthcare-associated infection in developed countries is around 10%. In developing countries, this figure is much higher. Most of these infections are preventable."

PATIENT SAFETY

According to Pittet, there are two main reasons why patient safety is still a growing problem. "The first is that although healthcare is progressing, some of that progress comes with an increased risk," he says.

"For example, there are now programmes to transplant pig livers to humans – because pig livers are of a good size and you can make them relatively compatible with human function. But organs are not sterile and can contain some viral particles or something like that. One day, no doubt, we will do a transplant of a liver in a human from a pig, and that human will probably carry some pig viruses that we are currently unaware of."

"Often, when a new medical device is introduced, it is associated with an increased risk of infection," says Pittet. "Even if you try to keep to the guidelines on how to apply this medical device, and how to use it, it's new, so it's more prone to mistakes, or incorrect use. Infection associated with healthcare, in part at least, may be the price we have to pay for modern medicine."

"The other reason why patient safety is a growing problem is that we tend to recognise more and more that these risks exist. That said, some of the risks have always been there." But that is not the entire story.

"Infection is also due to the lack of education, applied
education, resources and correct behaviour," says Pittet. "Part of our challenge will be to promote appropriate hand-hygiene action at bedside because the relatively low compliance with hand hygiene is the primary reason for infection that crosses from one patient to another."

Hand hygiene is an institutional priority. "You also need a better system to remind people to clean their hands, and better products. The good news is that awareness of the problem is increasing."

CAREFUL HANDLING

This is certainly true in the UK, where the National Patient Safety Agency (NPSA) was launched in 2002 and is now implementing a national Clean Your Hands campaign to reduce infections in hospitals. This world-first programme focuses on how improving hand hygiene among healthcare workers can have a dramatic effect on the spread of infection.

Key elements of NPSA's campaign include the use of alcohol-based hand-rubs – which are 99.9% effective in killing bugs, including MRSA – near to every hospital bed. The UK's healthcare staff are also encouraging patients to get involved.

"Alcohol-based hand-rubs are 99.9% effective in killing bugs - including MRSA."

"The six-month pilot that we did in six hospital trusts in July 2003 to January 2004, before we rolled out in phases nationally from 2 September 2004, showed a very noticeable increase in hand-hygiene compliance over the period of the pilot, and that's what we're trying to replicate nationally," says NPSA joint chief executive, Susan Williams.

At the time of writing, 100% of NHS Trusts in Wales and about 99% of NHS Trusts in England have signed up to the Clean Your Hands campaign.

Early in 2004, Britain's Health Minister launched the NPSA's programme to put in place a National Reporting and Learning System (NRLS) for patient safety problems – the first of its kind worldwide. The system is designed to draw together reports of patient safety errors and systems failures from health professionals across England and Wales to help the NHS learn from things that go wrong.

By 31 December 2004, the NPSA hit its deadline to put a system in place to allow all 607 NHS organisations the capability to report patient safety incidents to the NRLS. The next step was to work with these organisations to further tailor their reporting route to best suit their needs. To date, 90% of NHS organisations are now reporting through their chosen route.

"The key thing, with all these safety changes, is that it requires a systems change within the hospital or medical unit," insists Williams. "It's not enough for us to recommend changes; you have to think through how you can achieve things at a local level."

"That means preparing the ground, training and awareness of staff, getting some local champions who will lead the programme within the organisation, and ensuring the alcohol gel is in place. It also needs constant reinforcement. We are quite keen to make sure that when we do put something out, what we're suggesting is implementable and we have a broad professional consensus that it's the right thing to do."

"What is interesting about patient safety, if you look at it internationally, is that, however it is funded – whether it's a mix of private insurance or government, or predominately independently funded, with all the different ways health services are structured – the error rate in research is roughly the same. That suggests to me that we are dealing with something which is much more about clinical systems and professional training than the particular ways in which different health services are incentivised."

"Often, when a new medical device is introduced, it is associated with an increased risk of infection."

PRIVATE DIFFICULTIES

In the USA, the Patient Safety Institute (PSI) is a non-profit membership organisation governed by USA's leading consumer, physician and hospital advocates to ensure patients receive care from a healthcare provider who has access, with the patient's permission, to their personal health record, regardless of the source.

It was formed to provide the US healthcare industry with a commonly owned, inclusive network utility to support Regional Health Information Organisations. Thus they can deliver real-time healthcare information to achieve, among other things, safer care by reducing medical errors caused by incomplete clinical information.

"Our perspective is creating interoperability of readily available information at the point of care," says Johnny Walker, PSI's CEO. "But we don't have anything like the resources of the UK's NHS so we're having to accomplish the same goal with different means."

"The big difference is that our consumers are adamantly not comfortable with a common healthcare information number or identifier. And if there are two medical providers across the street from each other, they are, as it stands right now, disinclined to share information about a patient because they don't want the other one to reap some perceived competitive advantage. So there has to be a trusted third party, like the PSI, to perform the function of an NHS."

Given that most Americans have to pay for private medical service, and the USA has a healthy compensation culture, is patient safety now a major issue? "Right now there isn't any issue on this subject," notes Walker, "although all the research indicates safer care is less expensive overall."

"The trouble is that firstly this is not necessarily believed and secondly the way that compensation is set up means there isn't necessarily any benefit for practising safer care. So the expenses of lesser quality or less safety somehow gets shoved off on somebody else. In fact, in many cases it's actually profitable, in some situations, to be unsafe. If you go into a hospital and you make an error but they don't ever identify what that error is then that causes the patient to stay there longer and have more treatment and more tests done."

"In our system you actually get more money from a medical error than if you got it right the first time and got them out. What has been proven here in the USA is that getting the information to the hospitals, and more importantly to the consumers, seems to have more impact than anything else."

ADDRESSING THE PROBLEM

The National Patient Safety Foundation (NPSF) is a non-profit organisation that encourages the interests of the USA's health professionals, systems and human factors specialists, amongst others, in exploring the professional, consumer and systems issues related to patient safety. This includes the prevention of healthcare errors and the elimination or mitigation of patient injury caused by healthcare errors.

"In America healthcare is not a unified system where you can make a change by some edict from the government; it's much more complex," says Paul Gluck, MD, vice chair of the board of the USA's NPSF.

But is America now addressing the problem of clean hands and patient safety? "Yes," believes Gluck. "And healthcare providers have alcohol-based hand wipes. The point is that these simple interventions are often circumvented because of circumstances such as overwork and other things, so the providers try and do the best they can. What we have to do is develop systems to make it easier for people to do the right thing and still maintain their workload."

"Interventions are often circumvented because of circumstances such as overwork."

"Patient safety is more like driving a car than baking a cake. If we post a big sign over a hospital or in my office stating, 'All providers must wash their hands between patients', it is still going to be circumvented unless we make it easier. If you're going to bake a cake, and I give you a recipe of how to bake a cake – a set of rules – and you follow that recipe explicitly, then you'll get a good cake."

"But patient safety is not like that. I think it's more like driving a car. And when you drive a car you have a set of overarching principles, but you never know what eventuality is going to come up next. And the same applies to patient safety."

"So we can set up our rules for hand-washing and we can set up all these dispensers and make it easier and increase the hand cleanliness rate 80% or 90% and lower the nosocomial infection rate but there'll be a new hazard that will crop up, just like when you drive a car."