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THE WATT GROUP REPORT
CHAPTER 4 ANTECEDENTS
The Victoria Infirmary, built in 1893, is no longer fit for purpose as a busy general hospital. It has suffered from a prolonged period of uncertainty about its future with consequent planning blight and serious under-investment in the fabric of the building. The Hospital has faced a long-standing series of difficulties, well publicised in often hostile media coverage.
The above factors have had 2 consequences:
(a) Difficulties in recruitment (30% shortfall of the nursing establishment in the medical unit where the outbreak occurred) with reliance on bank and agency staff to fill the gaps;
(b) Lowering of morale and the development of a "siege" mentality in some Trust staff.
We recognise the wide array of competing pressures on the time, energy and focus of individuals, managers and on the resources of an NHS Trust, and also recognise the dedication of hard-pressed staff working in difficult conditions.
Causal and Associated Factors
The exact route(s) of transmission within the ward cannot be established with certainty, but could be one or more of the following:
(1) Patient-to-patient contact, either directly or via the environment or via staff;
(2) Through inadequately decontaminated equipment and environment;
(3) By contamination of food at ward level and subsequent storage at unsatisfactory temperatures.
Hand Washing
There is evidence that before the outbreak there were insufficient hand washing facilities in the wards concerned and no audit evidence of compliance with hand washing guidelines. Compliance with hand washing guidelines is a problem throughout the NHS. The Group considers that there needs to be a "culture change" so that it is as unacceptable for health care workers not to comply with hand washing guidelines as it is for a surgeon to commence an operation without scrubbing up, or without using sterile instruments. Trusts should recognise the central importance of hand washing.
Recommendation
1. That Trusts should put in place structured audits of hand washing for all groups of staff, including medical, bank, agency and night staff.
Cleaning
The layout of the ward, especially the space between beds; the surface finishes; and state of the fabric, will have made it a challenge to clean effectively.
It is clear that there were widespread concerns about the quality and frequency of ward cleaning in the Victoria Infirmary before, during and after the outbreak. The contract specification is inadequate and ward staff have long complained about this. The contract is now the subject of renegotiation by the management of the Trust and the contractor.
There was a lack of clarity about who was responsible for the cleanliness of ward areas and a lack of regular audits. Although regular monitoring occurred, improvements were not effected.
The Group was concerned that in spite of these issues and of the recent Health and Safety Executive Report on the hospital, which expressed major concerns in relation to cleanliness, we were led to believe by the Trust that there were no serious issues arising from the recent assessment by Audit Scotland of the Trust's compliance with the Clinical Standards Board for Scotland's Healthcare Associated Infection (HAI) and Cleaning Services standards, and "A Clean Bill of Health: a review of domestic services in Scottish hospitals" published in April 2000.
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Recommendations
2. That the cleaning specification in wards and departments should be set by the senior nurse responsible for the area and each ward/departmental manager in collaboration with the relevant Infection Control Team and Domestic Services Manager. Cleaning against this specification should be subject to rigorous monitoring and action to correct deficiencies. Failure to meet the specification should be subject to formal audit and review within each hospital and be subject to public disclosure.
3. That the ward/departmental manager should have unambiguous responsibility and be held accountable for all aspects of hygiene in their area. They must have commensurate authority, skills and resources (time and money) to discharge this responsibility.
4. That Audit Scotland reports are reviewed carefully by the management of Trusts,andthat appropriate action is taken to respond to them.
5. That the Clinical Standards Board for Scotland ensures that there are reliable mechanisms in place to monitor compliance with its cleaning services standards.
Decontamination of Staff/Changing Facilities
Although faecal contamination of staff was believed to have resulted in occupationally acquired salmonella infection, the Group was not provided with evidence that these incidents had been clearly documented and investigated. Also, there did not appear to be clear guidelines for decontamination of staff, nor for the treatment and laundering of soiled uniforms. It was clear that staff travelled to and from work in uniform and that many laundered their uniforms at home. The Trust's uniform policy was more of a dress code guideline. It did not give guidance as to how uniforms should be laundered, or whether a spare should be brought to work in case of a contamination incident, nor how uniforms should be treated in the event of such an incident. Staff changing facilities were inadequate and there was evidence of staff changing into clinical uniforms in the sluice room (classed as a "dirty" utility room) or domestic services room. Travelling to work in uniform and changing as described above are not positive symbols of good hygiene and will undermine public confidence.
Recommendations
6. That exposure of staff to faeces should be documented through the Incident Reporting Procedure as thoroughly as exposure to any other biological (body) fluids.
7. That specific guidelines and facilities (washing, showering, cleaning uniforms) should be available in every hospital for the decontamination of staff who become grossly contaminated from body fluids (blood, urine, faeces and so on).
8. That every Trust should have a staff uniform policy that ensures that:
(a) all staff uniforms are laundered by, or under the auspices of, the NHS;
(b) the widespread practice of staff travelling to and from work in (potentially contaminated) uniforms ceases; and
(c) adequate staff changing and decontamination facilities are provided.
Nursing Documentation
There was insufficient information about the excretions of patients so that it was unclear whether certain patients had diarrhoea at the time of admission or subsequently developed it. Guidance given to nursing staff by the Infection Control Staff was not readily documented within the nursing notes and there was no clear written guidance to all staff members that specific patients suffering from diarrhoea were to have enteric precautions implemented. There was failure to clearly document individuals having loose stools; the number of stools passed; and their consistency in the nursing notes. The first visible sign of enteric precaution documentation followed the diagnosis of
Salmonella infection.
Recommendations
9. That nursing notes/care plans should clearly reflect the need for enteric precautions in individuals suffering from loose stools /diarrhoea.
10. That nursing documentation should be improved so that key information and advice relating to infection control measures can be communicated to all relevant staff.
11. That clear infection control guidance to all staff on how to nurse a patient with loose stools/diarrhoea should be provided within the infection control manual.
Patient Movement
The Hospital was extremely busy before and during the outbreak with considerable patient movement. It is a common practice in the NHS for patients to be moved from bed area to bed area and from ward to ward. Sometimes there are clinical reasons for this but it has also been actively pursued to increase efficiency in the throughput of patients: e.g., it is routine for patients to be admitted to an assessment ward, then to a specialty ward and to be moved again if beds are unavailable. They may also be transferred to a discharge lounge, another form of ward, before they eventually leave hospital. Although probably not relating directly to the patients concerned in the outbreak, the Group considers that this practice does carry serious disadvantages - it confuses patients and they feel there is no one person who is in full possession of the facts of their case; it increases workload and puts an extra burden on communication between patient and staff and between staff and staff. Crucially, it also places an added burden on the control of infection - greater cleaning and decontamination is required and facts about patients such as their bowel movements may be lost or misinterpreted.
Recommendation
12. That there should be careful consideration nationally on reducing the movement of patients between wards in hospitals so that the likelihood of outbreaks occurring is minimised and when they do occur they are contained within as defined a location as possible.
Ward Environment
The layout of the ward, cramped conditions, insufficient single rooms for isolation, paucity of storage facilities and the state of the fabric, were not conducive to compliance with Infection Control Guidelines. They were not, however, in themselves a reason for non-compliance; many hospitals in Scotland pose similar challenges.
Recommendation
13. That a scientific meeting be organised at which experience and ideas relating to the specific infection control challenges of old buildings be shared and that following this the SEHD should issue guidance on the upgrading and maintenance of such buildings.
Ward Equipment
The demarcation of nursing and domestic staff roles in cleaning ward equipment was not clearly understood by nursing or domestic staff. At interviews, there was a lack of clarity as to who had overall responsibility. Also, the level of basic ward equipment, especially hoist slings and commodes in the ward concerned, was insufficient. This must have led to considerable communal sharing, putting greater strain on the decontamination process.
Recommendations
14. That Trusts ensure that levels of basic ward equipment (e.g., hoist slings, commodes) are sufficient to reduce the communal use of such equipment and reduce the risk of cross-contamination due to inadequate decontamination.
15. That Trusts develop policies which clearly identify the accountabilities of nursing and domestic staff in the cleaning of ward furniture and apparatus, including baths, food trolleys and "clinical" equipment and that clearly identify who has overall responsibility.
Space Considerations
Valiant attempts had been made to improve the Victorian layout of some wards (e.g., to give greater privacy and patient amenity) by changing their internal configuration. This applied to the wards affected by the outbreak. In doing so, however, it would appear that the distances between beds were reduced and patients were therefore in closer contact with one another than had applied previously. In addition, there was inadequate ancillary accommodation: clean and dirty utility rooms, staff changing rooms, domestic services areas and staff bases.
Overcrowding is a recognised factor in the causation of healthcare associated infections. Standards of ward accommodation (to reduce the likelihood of outbreaks of cross infection and to maximise their containment if they do occur) should be set nationally and be effected by a specific funding programme. These standards should include, amongst other things, sufficient hand washing facilities, en-suite toilet accommodation and clean preparation areas, segregation of domestic cleaning rooms and clean storage from dirty utility rooms.
The Scottish Health Facilities Note 30
14 should be used as a first point of reference on Infection Control on new builds and refurbishment projects. The Group fully supports this as a guide for best practice.
Recommendation
16. (a) That the Scottish Executive Health Department should reinforce the goodpractice contained within the Scottish Health Facilities Note 30, "InfectionControl in the built environment - design and planning," January 2002.
(b) That the NHS in Scotland develops, as a matter of urgency, standardsrelating to new builds and refurbishment projects incorporating, wherenecessary, the Scottish Health Facilities Note 30 guidance as best practiceand requires Trusts to produce action plans for compliance with Note 30.
Vacancies and Agency/Bank Nursing Staff
Nursing staff vacancies within the medical unit in which the outbreak took place were quoted to be 30% and it appears they were at this level before and during the outbreak. These vacancies were covered by agency and bank staff. This added to the numbers of staff passing through the wards. The Group is concerned both that infection control training of Agency staff may have been insufficient and that by increasing 'throughput' of staff there could have been an increased risk of cross infection.
There was also insufficient Infection Control Nurse cover, especially over the festive holiday period.
Recommendations
17. That control of an outbreak must include restriction of staff movement between wards and departments. When patients require infection control precautions to be implemented the nurses providing the care should, where possible, be the 'named nurse'. This should minimise the number of contacts of both the patient and the nurse. This may have implications for staffing of the ward but this will be temporary and not a high recurring cost.
18. That the Agency/Bank/Locum induction checklist should include explicit mention of Infection Control precautions in place.
19. That all Trusts should put in place assessments of the competencies of nursing staff in Infection Control and ensure that structured training programmes are established and the SEHD should consider with the Nursing Agency proprietors how competencies in Infection Control can be similarly assessed and delivered for Agency nurses. Similar training programmes should be put in place for medical and professions allied to medicine (PAM) staff.
Handling of Food at Ward Level
Although there was no clear evidence of this being a factor in the outbreak, the Group was concerned that:
(a) The ward refrigerator was not kept at the correct temperature;
(b) Ward staff received no formal training in food handling.
Recommendations
20. That all staff at ward or department level who handle food should receive training in food hygiene commensurate with their duties and in compliance with the Food Safety (General Food Hygiene) Regulations 1995.
21. That appliances used for storing or preparing food (whether in the ward or elsewhere) should be subject to appropriate inspection and the results recorded.
Clinical Waste Disposal
The Health and Safety Executive commented in detail in their report about concerns relating to clinical waste disposal. We endorse their findings and comments.
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