The nadir that brought about national infection prevention and control policy

The lowest ebb is the turn of the tide. . . Loss and Gain, Henry Wadsworth Longfellow

As part of a wider research project to understand and assess the current important national infection prevention and control (IPC) policy documents, a mini review of the history of the nadir of IPC that preceded and generated their introduction was needed. This narrative considers the famous and infamous events in the UK history of IPC from the early 2000s onwards, describing the prevalent context before the Departments of Health were activated to change the system.

Despite an absence of numerical data on clinical outcomes and mortality, pressure built on the NHS Departments of Health as the media and the public became increasingly concerned about hospital-acquired infections (HAIs). Although there had been several publications before the National Audit Office (NAO, 2000) report on HAI, this report (from personal recollection) lit the proverbial blue touch paper when the media frequently repeated a statement therein which estimated that in the UK per annum, ‘5,000 deaths (1% of all deaths) might be primarily attributable to hospital acquired infection, and in a further 15,000 cases (3% of all deaths) hospital acquired infection might be a substantial contributor. . .. . . .a proportion of these deaths is avoidable’ (NAO, 2000). To emphasise, these were not UK data but extrapolated US data. The statement was preceded by a ‘data warning’: ‘. . .equivalent data are not available for the UK, and whilst accepting the difficulties in extrapolating [data] from one system of health care to another. . .. a crude comparison indicates. . .’ (NAO, 2000). Any emphasis on the data being non-UK, was met with more incredulity that nosocomial death rates in the UK were uncollected and thus unknown. The situation was amplified with large, high-profile outbreaks in the early to mid-2000s (Healthcare Commission, 2006,2007; Health Protection Scotland, 2003). Regardless of the availability of accurate data, the media sustained the pressure with exposés, e.g. secret swabbing of various hospital surfaces that erroneously found superbugs. Even though Goldacre (2005) demonstrated that the media knew the science and scientist were flawed, the mud stuck. Furthermore, sustained high-profile publicity greeted the data that were available (largely methicillin-resistant Staphylococcus aureus [MRSA] rates and Clostridium difficile [CDI] rates) which were inexorably going upwards (Health Protection Agency, 2009a, 2009b). All of which generated a general atmosphere of patients being afraid, not of the care required, but of the consequences of untreatable infections acquired in hospitals (King’s Fund, 2008). There was no escaping the facts: HAIs were real, increasing and patients were suffering.

Before the major outbreaks and government interjections, no one was explicitly responsible for IPC outcomes (there were no Directors of Infection Prevention and Control or Infection Control Managers). Officially, it seemed the buck stopped nowhere. Also lacking were explicit specifications of what an IPC-safe environment should include, and what IPC data indicated significant issues or safety. In addition, other competing priorities for which there were targets, took precedence, e.g. time spent in Accident & Emergency before admission. Further compounding the situation was the environment. Much of the built healthcare environment was dated and unable to cope with the demands of advanced interventional healthcare. The basics were also deficient; there were few cubicles to isolate patients and Victorian hospitals had few hand wash basins, even in the busiest of wards. Hand hygiene was poor (lowest among medical staff) and more often done after patient contact than before (Pittet, 2001). The benefits of alcohol-based hand rubs were yet to be fully appreciated. Many cleaning services had been privatised and from an IPC perspective this was often challenging. Furthermore, the monitoring of cleaning systems, such as it was, was done for internal consumption only. The lack of seriousness with which governments had up to that point taken in the problem is exemplified by the fact that participation in national surveillance of MRSA blood stream infections was, until 2001, voluntary (Duerden et al., 2015). These combined error-provoking factors—in the context of significant emerging nosocomial pathogens—led to unsafe practices and systems which were shockingly revealed in later major outbreak reports (Healthcare Commission, 2007, 2008). Even though Crown Immunity had been removed 20 years earlier, after an appalling outbreak of Salmonella at Stanley Royd Hospital (Collins, 1986), Trusts appeared accepting of the increasing infection rates and risks. The situation progressed possibly because whatever IPC teams did was insufficient; this was exemplified by the title of one unsuccessful MRSA outbreak report ‘Winning the battle but losing the war’ (Farrington et al., 1998). Furthermore, there was perhaps a flawed comfort in infection rates going up everywhere (smooth sailing fallacy) (Curran, 2017). The situation, combined with pressure from the public and media, resulted in a political response: the status quo—and prevalent mindsets—had to change.

Anyone for guidelines?

The initial IPC response to any novel or emerging nosocomial risk had been to produce a guideline. The first IPC guidance was published in the middle of a war (Harries et al., 1944). The first Staphylococcus aureus specific guidance was produced in 1959 (Medical Advisory Committee, 1959). The response to MRSA, which first emerged as case reports in the late 1950s, came as epidemic strains became prevalent (Anon, 1986). Frequent updates were necessary due to a lack of success and difficulties in compliance (Anon, 1990, 1998). The most recent iteration came in 2006 at the height of the epidemic (Coia et al., 2006). As the guidance had failed (at least for the first three productions) to halt the rise in MRSA, further drastic actions were deemed necessary. Having been criticised for not having statistics, the government sought to produce them. Unfortunately, the first report on mortality from the Office for National Statistics showed a 15-fold increase in ‘superbug deaths’ (800 per annum in 2002) (BBC, 2004a). Having made the voluntary MRSA bacteria surveillance mandatory in 2001, the NAO web-published in July 2004 what the media termed ‘superbug league tables’ and thus the full extent of the problem became visible to all (BBC, 2004b). A ministerial response came, on Friday 5 November 2004, from the Secretary of State for Health, who, in a landmark announcement, stated: ‘I expect MRSA bloodstream infection rates to be halved in our hospitals by 2008’ (BBC, 2004c). And perhaps for the first time, someone, albeit organisations, were given the responsibility: ‘NHS Acute Trusts will be tasked with achieving a year-on-year reduction’. Furthermore, those responsible were informed this was, as no IPCT would have described at the time, ‘achievable, measurable and not too burdensome’ (BBC 2004c). Also, and initially not aligned, healthcare quality improvement emerged to become a norm and a necessity after alarming reports of healthcare having been shown statistically to be as dangerous as bungee jumping (Smith, 2016).

This situation of poor environments, procedures, increasing infection rates and accepted nosocomial mortality was to be countered. Having made the statement that MRSA blood stream infections were to be halved, the Departments of Health sought to provide policy documents to enable it to happen. These IPC priority documents (of which there have been many published) were researched to determine their part in the success or otherwise of IPC in subsequent years. They are the topic of the second paper.