Policy responses and statements

Name of organisation:

NHS Quality Improvement Scotland (NHS QIS)

Name of policy document:

Draft Standards for Healthcare Associated Infection (HAI)

Deadline for response:

31 October 2007

Aims and Objectives:

• To develop national standards to quality assure services provided in all clinical settings and for support services in NHSScotland, building on and, where appropriate, updating the existing CSBS HAI Infection Control standards.
  
• To ensure the standards fulfil the requirements detailed in the NHS QIS Healthcare Associated Infection scoping report by:
  
  - encompassing the 5 key areas of education and training, patient focus and public involvement, prevention and control of infection, environment and equipment and compliance management.
  
  - including selected elements relating to clinical governance that are of particular importance to Healthcare Associated Infection, including information provision, professional training and education of staff and evidence-based practice.
  
  - To produce a robust, accompanying self-assessment framework (SAF) and guidance document to facilitate the capture of high quality data/information from NHS boards as part of the future live peer review programme.
  
• To recommend a robust peer review methodology, applicable to Healthcare Associated Infection for use in the future live peer review programme.

COMMENTS ON
NHS QUALITY IMPROVEMENT SCOTLAND (NHS QIS)
DRAFT STANDARDS FOR HEALTHCARE ASSOCIATED INFECTION (HAI)

The Royal College of Physicians of Edinburgh is pleased to respond to NHS QIS on Draft Standards for Healthcare Associated Infection (HAI).

GENERAL COMMENTS

Thank you for asking the Royal College of Physicians of Edinburgh to comment on this document.  There has clearly been a lot of work done already to develop these draft standards. The Royal College of Physicians of Edinburgh welcomes every attempt made to minimise the risk of infection in our management of patients.  It is only when we continue to do this that we can expect to make further significant inroads in clinical disease management.

Overall it was felt that, although the rationale for many of these Standard statements were laudable, the specifics were difficult to understand because they were too vague in practical detail.  This makes them open to variable interpretation, potentially making them either very hard, or conversely very easy to achieve.  It would be useful to provide more detail of what is actually required for any of these, and for instance, what “adherence” actually means.

As a matter of principle, one reviewer identified that eradication of all bacteria is rarely possible and rarely desirable.  It is important to be aware that commensal colonisation is usually the desirable outcome, and bacterial eradication is not usually what is required.  This concept could be misunderstood when reading this QIS document on HAI. 

The evidence base for this document seems to revolve around government policy documents, with very little reference to peer reviewed scientific outcome studies (one out of 37 references).  Some of the former will clearly refer to the latter, but overall this causes some concern.  There is also a huge amount of bureaucracy involved in this standard, and we hope this will not distract front-line clinical staff from actually doing what is required.

SPECIFIC COMMENTS

Standard 1

These essential criteria should become targets, which are part of the requirement that Health Boards and Chief Executive Officers must achieve.  There is a danger that a Health Board might allude to compliance with the standards simply by having Infection Control Staff and policies in place.  This is an example of where the standards could be more specific in their aims.

1.6: This is vitally important and could have an additional statement about lines of accountability and responsibility.  This statement should clarify the accountability and end responsibility of independent contractors involved in 'hotel services' within the hospital or health care environment

Standard 2

The rationale for this criterion is good.  The criteria are very vague, and assessment of compliance with these standards could be interpreted in many different ways.

Could there be a minimum “core-dataset” that is recommended for use across all Health Boards?  Perhaps Health Protection Scotland could bring this together.

2b2:  If the public are involved in this it is important that they are properly informed, including issues about the difference between infection and colonisation.  The evidence base for this statement – and others – is not clear.  These seem to be based on government policy documents rather than scientific study (see comments above).

Hand hygiene and direct contact with a patient and their immediate environment has a body of evidence linking it to nosocomial infection and might do well to be the top of the list in 2b.2.  However, microbiological cleanliness may be different from visible cleanliness.

Standard 3

3a1:  Annual review of the Infection Control Manual is laudable, but what is the real practical implication of this?  The current Lanarkshire Control of Infection Manual runs to over 290 pages of carefully researched Control of Infection advice.  The annual review of such a document would be a full time job for an individual.

3a4:  Standard 3a.4 seeking NHS Boards to ensure adherence to current antimicrobial guidance appears somewhat broad and non-specific.  These standards appear to fail to recognise some of the guidance around antimicrobial stewardship set out in the APP & P document.  This national framework for antimicrobial prescribing in acute hospitals in Scotland has also recently been revised to adopt a somewhat broader remit.  As prudent antimicrobial prescribing goes hand in hand with healthcare acquired infection, we would have thought better linkage regarding key recommendations would enhance and reiterate the importance of measures to improve the quality of prescribing in healthcare settings.

Which Guidelines are this standard actually referring to?

3a5: An indication of how frequently the plan needs to be tested should be included.

Standard 4

The standards for cleaning and maintenance of equipment which now is fixed to most patient clinical areas are inadequate. Sometimes nurses are not allowed to interfere with this equipment even if the patient has had MRSA or Clostridium difficile. This is a simple example of a situation that needs to be addressed by standards such as this.

Standard 5

There is a sense in the broader NHS that clinicians, particularly physicians, are not engaged into the overall philosophy and culture of HAI.  We wonder if under compliance the standards may wish to reflect around how greater and active engagement of frontline clinical staff, particularly doctors, could be brought about by NHS Boards.

An importance should be attached to Infection Control Education which is at least akin to that apportioned to fire prevention and management.  This educational requirement is a primary responsibility of our universities, undergraduate training schools and all training school curricula for health care workers.  The task for NHS boards should be to maintain an established level of education rather than starting from scratch!

5b.4:  Other programmes should be included e.g. Outbreak management, Alert organism control, MRSA control, C.difficile control.

In addition to staff undertaking programmes, staff should be allowed to implement what they learn.  At times this is not allowed in PFI partnerships e.g. nurses cleaning equipment, which has been used by patients with known infections.

SUMMARY

A lot of useful HAI criteria have been identified.  The practical consequences of how these are measured and assessed in routine clinical practice have not been so well thought through.  Without that sort of practical detail, this document stands the risk of making little sustainable impact.  It may benefit from greater consultation with front-line clinical staff.

There is concern that this could turn into a paper exercise which does not influence long-term change, resulting in little impact on infection control.  A more focussed approach that uses front line staff may be a more effective approach for achieving real long-term, sustainable change.  The College could possibly help in such a role, in terms of making implementation and evaluation of guidelines (not just HAI) more effective.

Thank you for asking us to comment.  We hope you find these comments constructive and useful.  If we can help clarify any of these issues, please do get back to us.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[31 October 2007]