This multidisciplinary Working Group was established by the Scottish Office Department of Health in June 1997 with a specific remit:
Details of the composition and membership of the Working Group are given in Appendix I.
Background
1 Hospitals throughout the world are in the midst of an unprecedented crisis following the rapid emergence of antimicrobial-resistant micro-organisms 1. Strains of methicillin-resistant staphylococcus aureus (MRSA) which are resistant to many other antimicrobial agents, including the quinolones, are now endemic in many hospitals leaving vancomycin as the sole agent in the first line of defence against infection 2
2. At any one time about one in ten patients acquires an infection after admission to an acute hospital 3. The current trend towards shorter lengths of stay, greater patient throughput and the increasing complexity of medical and surgical procedures only serve to heighten the problem of hospital acquired infection, (HAI) 4. Other predisposing factors, such as the indiscriminate use of antimicrobial agents and the increased movement of patients between wards and units mean that present patient populations, which are generally older and more ill than in the past, are at particular risk of infection 4. HAI is costly in terms of the distress and disability caused to the individual. It is also costly to National Health systems in terms of diagnosis, treatment and care 5
3. Seminal work by Haley in the United States 6 has produced convincing evidence that an organised HAI programme comprising surveillance, an intensive control programme and regular feedback of results is highly effective in reducing rates of HAI. Furthermore, pooling of standardised surveillance data collected from participating hospitals can add significantly to the value of local surveillance by placing local figures in a broader and more meaningful context.
Reasons for Review
4. There are already in existence several local, national and international imperatives which require that surveillance of HAI is undertaken and the information obtained acted upon. At national level, certain Acts and Regulations impose standards within the hospital. These include The Health and Safety at Work etc Act (1974)7,The Food Safety Act (1990)8, The Management of Health and Safety at Work Regulations (1992) 9, and The Control of Substances Hazardous to Health Regulations (1994) 10 More recently, both the House of Lords Select Committee on Science and Technology and a Sub-Group of the Standing Medical Advisory Committee in England have prepared reports in the related area of antimicrobial resistance 11,12 A recent EU Conference also discussed this issue in depth. The National Audit Office, (NAO), is currently undertaking a value for money investigation into the management and control of HAI in English Acute Trusts. The NAO expects to report its findings to Parliament sometime between April and June 1999. European initiatives and accompanying legislation are also thought to be imminent.
"The Government will amend Trusts` statutory duties to make explicit their responsibility for quality Of care …. Trust Chief Executives will carry ultimate accountability for the quality of care provided by their Trust. in the same way as they are already accountable for their Trust's proper use of resources."
In the new era of clinical governance, HAI rates could well be included in the list of quality indicators against which a Trust's performance is assessed.
6. Against this background, the Scottish Office Department of Health has established this Working Group with a remit to prepare a framework for the implementation of a national system of HAI surveillance for the NHSiS.
7. The composition and membership of the Working Group are given in Appendix I.
Methodology
8. The Group met on nine occasions between June 1997 and September 1998 and took evidence from a number of individuals in Scotland and in other parts of the UK to obtain information on HAI surveillance systems in England and Wales. The members of the Working Group gratefully acknowledge the contribution made by these and other individuals whose names are listed at Appendix II.
9. The Group devised a series of questionnaires to obtain baseline data on the current status of, and attitude towards, HAI surveillance activity in the NHSiS. Detailed information is given on this aspect of the Group's work in Chapter 11. The members of the Working Group wish to place on record their gratitude to all the healthcare professionals who took the time and trouble to complete the questionnaires.
Scope of Review
10. Length of stay in hospital for many common conditions has been dramatically reduced in recent years. Shorter length of stay may reduce exposure to infection, but it also increases the likelihood of infection presenting after discharge from hospital. Any infection following day-case surgery will, by definition, manifest itself in the community and not in the hospital. Clearly, an HAI surveillance system that does not attempt to record post discharge infections is likely to result in a significant underestimate of the true incidence of HAI.
11. HAI surveillance is only one weapon, albeit an important one, in the armamentarium that can be used to reduce HAI rates. This report does not cover the prevention of infection, control of infection or the role of the Infection Control Team. For these and other aspects, the reader should refer to the recently published Scottish Infection Manual 14.