18 June 2011

The C Diff outbreaks at Stafford Hospital: Role of the HPA.

On Day 101 we heard from the health protection agency. This body, which is soon to be abolished, and have some of its functions assimilated into the DoH exists to guard the health of the public. They have dealings with GPs surgeries, Care Homes, a wide range of aspects of public health, Mental hospitals and hospitals. They were at pains to point out not regulators. They have no direct authority over any of the organisations that they deal with. Their role is to offer expert advice and support.
The Chairman asked on a number of occasions if they felt It would help if they had greater powers to ensure that their advice is headed, but they believed quite strongly that this would be counter productive. They work on a collaborative basis. They want hospitals to feel free to come to them for advice, without fearing any adverse consequences, and they believe that this very unthreatening way of working makes them effective in what they do.
Dealing with hospitals is only a small part, maybe 10% of the work that they do, and each member of the HPA will have a large number of hospitals in their area, so it is clear that they can have only a small part to play in this story, but I feel that it is a significant one.
The line of questioning was largely about C Diff. MRSA and C Diff became a huge issue across the NHS in the period 2005-2008. It was claiming lives throughout the country People were genuinely frightened of headline stories of hospital super bugs, and the idea that antibiotics which we have depended on for so long are powerless to help in some cases.  This level of justified fear made it a  major political issue. Dealing with these infections, and reducing the number of cases became the number one priority for hospitals at that time. Stafford did have great concerns about MRSA and the deep cleaning programmes introduced at this time, together with a much greater awareness of proper prescribing of antibiotics worked with considerable success to greatly reduce the incidents of this infection.  
The HPA had a role to play as they were experts that could be called in to give Advice and Support. They would have been I think a very comforting presence for hospitals at a time when an outbreak occurred, when the hospitals needed to take action quickly
The Chairman asked about their recommendations for reducing the incidence of C diff. MRSA patients are now routinely screened when they go into hospital and he wondered if it would help to screen for C Diff as well. Dr Azfa patiently explained that this would not serve any useful purpose. She wanted us to understand the nature of C Diff. Many of us carry the bacteria for C Diff in our bowel. It only becomes a problem if the immune system is compromised or if the patient has been over prescribed antibiotics. So many people will find that because of other conditions that the C Diff which they carry will become active during a period of ill health.   C Diff cannot be prevented. It can only be controlled.
Keeping CDiff under control is a matter of having the right nursing techniques, right antibiotics, right hygiene and being able to isolate people if needs be.
Preventing it is a much more difficult matter. There are some recent articles  and here  which clearly link the rise in the incidence of hospital infections with the way in which our food, especially meat and chicken is being produced. This is something that we should all rightly be concerned about. The bugs are often described as Hospital Superbugs That is a misnomer. They are clearly a huge challenge when they do appear in hospital, but if they are arising from problems in the food chain, as well as from over prescription of antibiotics to us as individuals, then this is a much bigger problem.
Dr Azfa was I think keen to tell us more about the nature of the bacteria that we all carry in our guts and the factors that affect them, but the Lawyer under time pressure curtailed the discussion.
In terms of the timing of events there had been a significant outbreak in 2006 at the time when CDiff outbreaks were occurring throughout the country.  This came before Dr Azfa’s time at the HPA, but she was there for Clusters in 2008 and an outbreak in 2009.
A major problem that Stafford faced if an outbreak occurred was how to effectively isolate the patients. Dr Azfa felt that the hospital did not have enough side rooms, and therefore the next best thing would be to have a special cohort.  She had raised this issue at the time of the 2008 events and was still bringing it up at the meeting where she first became aware of the January 2009 outbreak.  The hospital needed to devote time energy and money to sorting this out. It may not have had any of these.
I was advocating it fairly strongly and consistently,
20 and hence you see it appearing in the minutes of
21 26 January meeting, at which point we were not aware of
22 this 2009 C.difficile outbreak beginning, because it's
23 through this meeting and subsequently formerly on
24 27 January meeting notes that I became formally aware of
25 it. So even before that knowledge, I am trying to -- to
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1 make it quite clear to the trust that, "You need in your
2 own mind to distinguish what isolations facilities you
3 need, you need isolation facilities for other reasons,
4 besides C.diff and MRSA. And you need to -- you know,
5 you need to clearly demonstrate within the breakdown of
6 cases that these are the breaches which has happened
7 because of MRSA patients not getting isolated, these due
8 to C.difficile, these are due to immuno-compromised
9 patients taking priority". when you
10 have limited isolation facility, the clinicians need to
11 prioritise who gets that first room first.

Her involvement in the 2008 and 2009 episodes was very interesting. I felt that it gave us a snap shot in to a time in the hospitals history when they were under very real stress.
In July 2008 the Healthcare commission was already well into the process of its investigation. Dr Azfa did not know any detail of this at this stage.  There was a meeting at which she was present and there was a prolonged discussion about whether the cases of CDiff which were occurring at that time amounted to an Outbreak or if they were Clusters. There is a distinction, a cluster is when the infection is arising from individuals, an outbreak is when it is being transmitted.   Dr Asfa felt it would have been helpful to think of the two distinct clusters that were occurring at that time as an outbreak, and felt that if this had happened it may have persuaded the PCT to find the money that the hospital needed in order to set up an adequate isolation facility.  The hospital was reluctant to declare an outbreak.  The Chairman asked her to offer an opinion about why they felt this way, and Dr Azfa speculated that it could be because the hospital was concerned about the reputational damage.  
Another reason that Dr Azfa would have favoured the declaration of an outbreak is that it makes it possible to involve the public in a much more open and informative way. She said that if you announced it as an outbreak then you would have signs and screens and taped off areas, and clear instructions to every member of the public to use gel and to stay away from the hospital if they themselves were unwell.  Her message was that infection is everyone’s responsibility.
Dr Azfa was a pains to point out that it is not possible to prevent C Diff occurring, for the reasons I have indicated. The emphasis has to be on helping hospitals to deal with the outbreaks that do occur as well as possible. She did not feel that the hospital was as well prepared for the outbreak as it might have been, and she mentioned about carrying out an audit of commodes and finding that they were all dirty.  A report flashed up on the screen mentioned  that infection control had not been made any easier by a confused patient with profuse diarrhoea wandering about in the ward and having accidents.
Sick patients with Diarrhoea, in a time when the hospital was already short of staff, can of course easily be compounded by staff becoming sick.  It is very easy for things to run out of hand. At times like this calm and authoritative leadership can make a positive difference and can help to guide a hospital through what will always be a difficult experience.  I think it is important to remember what else was going on in this hospital at this time. The leaders of the trust will have been very much distracted by the Investigation process, and all the adverse publicity that accompanied it.  I think it is fair to assume that the Hospital was probably not functioning at the optimum level.
The intervals between the 2008 and 2009 outbreaks should ideally have been used to set up an isolation facility but things calmed down, the resources were not forthcoming from the PCT and other things, including dealing with the ongoing HCC investigation took priority.
. If -- if you look at the interval between the number of
15 cases -- in July 2008 were eight to nine at any one time
16 in the -- in the context of that outbreak. The trust is
17 demonstrating continued reduction in the number of
18 C.difficile cases and meeting all the targets, so
19 they've -- it's not as if there were alarm bells going
20 on

Mr McCraken was asked if he thought that infection would be more likely to occur or spread in a hospital that was experiencing pressure. He had no hesitation in answering “Yes!”
The second Outbreak, this time clearly described as an outbreak, occurred in Spring 2009.
By this time the hospital was awaiting the publication of the HCC report and there were a whole series of increasingly bitter rows going on in the background.  Dr Azfa refers to the level of chaos that this was bringing to the hospital at that time.
In 2009, again, what information was in the public
18 domain that the Healthcare Commission inquiry report was
19 imminent, was something I was aware of and in fact it
20 became quite -- how do I put it? -- quite a significant
21 issue for us who were trying to deal with the problem of
22 the outbreak as it was unfolding, in February --
23 February and March 2009, to -- to be, you know, to be
24 mindful of the fact that the -- that the trust was under
25 quite a lot of pressure at the time, because the
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1 Healthcare Commission report was coming out.
2 And it was evident from, you know, the way -- you
3 know, particularly with Helen Moss, she was having to
4 rush into the meeting and leave early, although she was
5 meant to be chairing those meetings. And another
6 something which I did not get the opportunity to tell
7 your learned -- learned selves is that in March -- early
8 in March -- late February/early March 2009, when
9 I raised my concerns with my line manager, the unit
10 director and the regional director of HPA at the time,
11 we were -- we asked to meet the chief executive, myself
12 and my unit director. And that meeting -- and as well
13 as the medical director, Dr Val Suarez, at the time.
14 That meeting actually did not happen, because both of
15 them stepped down on roundabout 3 March, which was the
16 date when we were supposed to meet them.

It is certainly the case that people died in the C Diff outbreaks of 2008 and 2009. It is an unpleasant and undignified way for people to come to the end of their life and the relatives who experienced these sad events will always carry the burden of this.  Could any of these deaths have been prevented? I am not sure that anyone can say. 

I attach for interest the coverage of the HPA evidence from one of the local papers, who clearly do not have the opportunity to go into the kind of detail that is possible on line.

The Health Protection Agency desperately tried to get managers at the hospital to change the way they handled clostridium difficile infections after two outbreaks in 2008.
But managers at the scandal-hit trust refused to follow their advice and a much larger outbreak erupted in 2009.
It spread to several wards at both Stafford and Cannock Hospitals, killing 10 and infecting many more.
Yesterday the Francis Inquiry heard evidence from Justin McCracken, chief executive of the Health Protection Agency, who revealed the hospital repeatedly refused to act on advice and was reluctant to declare outbreaks – possibly due to a fear of bad publicity.
There was an outbreak of c.diff in July 2008 with eight cases on one ward, then in September and October there was another outbreak with four cases in 19 days.
Mr McCracken told the inquiry the HPA had “serious concerns” about the lack of an isolation ward, a shortage of staffing and cleaning of hospital wards.
He told the inquiry: “We felt we were banging our heads against a brick wall.
“It is clearly a matter of deep regret that our advice was not followed.”