Vol. 662 No. 1
118 Deputy Alan Shatter asked the Minister for Health and Children her views on the level of hospital infections such as MRSA and C. difficile; the action taken in the past three years to tackle this problem; and her further views on the need for a new programme to be put in place in order to eliminate the existence of such diseases within hospitals. [31909/08]
121 Deputy Noel J. Coonan asked the Minister for Health and Children if she is satisfied with the progress being made in tackling hospital acquired infections; her views on giving the Health Information Quality Authority statutory powers to enforce the recommendations when HIQA carries out hygiene audits on health facilities; and if she will make a statement on the matter. [32269/08]
254 Deputy James Reilly asked the Minister for Health and Children if she is satisfied with the progress being made in tackling hospital acquired infections; her views on giving the Health Information Quality Authority statutory powers to enforce the recommendations when HIQA carries out hygiene audits on health facilities; and if she will make a statement on the matter. [32676/08]
I propose to take Questions Nos. 118, 121 and 254 together.
Tackling all health care associated infections, including MRSA and C. difficile, continues to be a priority for the Government and the Health Service Executive. Health care acquired infections are not a new phenomenon and have always been a potential complication of medical treatment, especially in hospitals. That is the case worldwide.
As the Deputies will be aware, the HSE launched a national infection control action plan in March 2007. The aim over the period of the plan is to reduce health care acquired infections by 20%, MRSA infection by 30% and antibiotic consumption by more than 20%.
A new national surveillance system has been established to collect data and provide information on health care acquired infections in our health system. These data covers four areas, namely, bloodstream infection, antibiotic consumption, alcohol gel use and, from 2008 onwards, MRSA surveillance in intensive care units.
Data in respect of the first three areas have been compiled and published for 2006 and 2007. This report provides essential data that will serve as a benchmark for assessing progress in the future. I firmly believe that you cannot manage what you do not measure. With this system we have now begun a very useful measurement process. The results so far show some improvement in 2007 over 2006. The overall bloodstream infection rate was lower in 2007 compared to 2006. The overall proportion of MRSA was also lower in 2007 compared to 2006, down from 42.4% to 38.5%.
Since 4 May this year, C. difficile has become a notifiable disease and all cases now have to be reported to the relevant department of public health. The Health Protection Surveillance Centre of the HSE published guidelines for the surveillance, management and control of C. difficile associated diseases in May 2008. This publication gives national guidance and deals with the isolation of C. difficile ribotype 027 for the first time in Irish hospitals. The guidelines will be a valuable resource in assisting in the prevention, management and control of this infectious disease.
Other measures taken to reduce the incidence of health care acquired infections include the appointment of additional infection control staff, education campaigns for health care staff and the public around the prudent use of antibiotics and the use of designated private beds for isolation purposes where required for patients who contracted health care acquired infections. In addition, new environmental building guidelines to inform infection control policy in all new builds and refurbishments are to be published shortly by the HSE.
An important part of infection control is hygiene. The Health Information and Quality Authority, undertook a comprehensive review of hygiene in our acute hospitals in 2007 and published its report last November. The report represents a thorough assessment of how hygiene services are provided and managed in 51 HSE-funded acute-care hospitals. HIQA is following up on this review to ensure that deficits identified during that process are rectified and the authority has already commenced a further national review this month. HIQA is also due to publish infection prevention and control standards later this year. When finalised, these, along with the national hygiene standards, will provide a comprehensive framework to control infection in all health care settings. I believe this process is sufficiently robust to achieve the required improvements in this area and further enforcement provisions are not necessary at this time.
While accepting that not all health care acquired infections are preventable, I am satisfied that significant steps are being taken to reduce the rates of health care acquired infections generally and to treat them promptly when they occur.
Will the Minister accept that it was an act of unforgivable Government negligence that we did not until recently have a national surveillance system? Will she agree that the absence of such a system meant that her Department, for many years and certainly throughout the 11 years she has been a Minister in the recent Administrations, had no overall perspective on the level of hospital acquired diseases? Will she also accept that what is now proposed is grossly inadequate and that what we need is a revolutionary approach to reduce radically the level of such infections? Does the Minister agree that from the general public's perspective, a reduction in MRSA infection of 30% over a five-year period is grossly inadequate? Of the 526 cases recorded in 2007, the vast majority should not have occurred. Will the Minister accept that large numbers of people are now terrified to go into hospital for fear that any medical assistance they receive may be overshadowed by the detrimental impact on their health of acquiring an infection?
My family and I are personally aware of the impact of this particular hospital acquired infection. Three years ago, my mother-in-law went into Tallaght Hospital for treatment of a medical condition. She acquired MRSA within weeks and never walked out again. Does the Minister not agree there is a complacency within her Department and the HSE, as evidenced by the minimal objectives that are sought to be achieved within the next five years, and that a radically different approach is required?
I am sorry to hear of the circumstances experienced by the Deputy's mother-in-law. I recall, as a young girl, hearing people talking about the "hospital bug". In more recent years we have been able to put names on some of these infections. The reality is that the infrastructure of the health system is still catching up. For example, we have a long way to go in terms of the number of single rooms in hospitals. The hospital of the future will consist entirely of single rooms, as is the case, for instance, with the new national paediatric hospital and the new build at St. Vincent's Hospital. That is the future. Such an arrangement will minimise the capacity for infections to spread in a hospital environment. People who are ill, particularly if they are frail and elderly, are more vulnerable to infections.
The most significant single action we can take to address this problem is to reduce greatly the incidence of antibiotic prescribing. The countries that have the best record in controlling hospital acquired infections, such as Holland, are those where the level of antibiotic subscribing is substantially lower than in Ireland. That is why a targeted reduction in the incidence of infection of even 30%, which may not sound substantial, will in itself be a challenge to meet because it requires the education of both general practitioners and patients. Many patients feel they have been betrayed or let down by their GP if they do not receive a prescription for antibiotics. I have had this discussion with friends, many of whom are well informed. Of the 14 Members present in the Chamber, three or four are likely to be MRSA carriers.
In addition to a reduction in antibiotic prescribing and the need for a significant education campaign, there will be recruitment of specialised pharmacists, microbiologists and other experts to work at hospital level, where infection is a particular problem. Until two or three years ago, no hand-washing campaign was in place. It remains a major challenge to ensure health professionals adhere to good hand-washing practices. This is not just the case in Ireland but also in many other jurisdictions. Appropriate hand-washing using alcohol gels by health professionals and patients' visitors has a significant role to play in helping to prevent the spread of infection in the hospital environment.
Last year, I asked the HSE to ensure all private beds in public hospitals which heretofore were ring-fenced for private patients were made available for patients requiring isolation. That is being done. It is one aspect of the provision of the required infrastructure within the health system. However, I accept that we have a long way to go in this area.
I acknowledge there is a serious problem here. I echo the concerns of my colleague, Deputy Shatter, at the approach being taken. The Minister mentioned Holland, but there is a lot more going on there than just the prescription of fewer antibiotics. When patients are admitted to hospital there they are kept in a separate area from other patients until their status is known. If they are found to be MRSA positive they are put into isolation rooms, but we do not have sufficient isolation rooms. The Minister is right in saying that our health service has been chronically underfunded in the last 20 years and we have only recently been catching up. What can we do, however? We could start by putting Perspex divides between beds in wards to try to create a clinically clean area around each bed. We could also start to reduce overcrowding by, as I alluded to earlier, getting some of the people who no longer need to be there out of hospital into community facilities, by reinstigating the home-first service and by making beds available in the community to transfer patients from our public hospitals. Overcrowding is one of the biggest issues concerning cross-infection.
The Minister is also correct to say that hand-washing is important, but while alcohol-gel works for MRSA it will not work for clostridium difficile. I welcome the Minister's comments about patients' interpretation of general practice. I do not know how many times I have heard people say, "Well, that was a waste of time, I didn't get an antibiotic." It is not about wasting time, however, it is about getting an opinion on what is wrong and what is necessary to get a person better, which does not always entail an antibiotic. The Minister is absolutely right in that regard.
Does the Minister intend to invest in some of the measures to which I have alluded? With 526 cases of MRSA in 2007 and 780 cases of clostridium difficile as of May 2008, what will the medical-legal bill be for all this if we do not act a lot faster than is intended?
I will not get into the medical-legal bill. There are many lawyers going around this country dealing with that issue and I will not assist them in any way. The fact that we now have the data, however, is hugely positive. We do not know what the figures were ten years ago because we never measured them so we do not know if it is getting worse. There was an improvement in 2007 over 2006, but I do not want to make a big issue of it so let us see how we do in 2008. One of the big benefits of co-location is that it will give the main public hospitals the capacity for a lot more single rooms and better infrastructure. The sooner that happens the better. I should not be raising issues that stir great excitement in my colleagues opposite, but it is a fact because we will not have the capital funding.
It does not stir excitement with the bankers now, though.
I must tell the Deputy that we will not have the capital funding to do all the things we would love to do with our public hospitals. We have over 40 hospitals, many of which are very old. If we were establishing a health system today we would not have 40 hospitals but we do have that number of functioning hospitals and in the short to medium-term it is just not possible to provide the capital infrastructure to upgrade them to the standard we would like to see.
The recruitment of key personnel, such as pharmacists, microbiologists and infection-control nurses, and the major information awareness campaign in the public and private health system will greatly assist in this regard. Setting the target is a challenge in itself. I know Deputy Shatter takes the view that 30% is very low, but it is not. If we can reduce the incidence of MRSA and health care-acquired infections by one third over the next four years, it will be a major improvement. The United Kingdom set a similar target over a longer period. I would regard it as a satisfactory outcome if we can achieve that kind of improvement over that timeframe.
What steps has the Minister taken to ensure the implementation of the recommendations of the Health Protection Surveillance Centre concerning the monitoring and control of MRSA and C. difficile? Among the recommendations is the provision of single-room isolation units for people who have been identified with C. difficile. There is a need to ensure that all health care workers should go through a mandatory introduction to infection control. There is also a need to ensure the proper monitoring of antibiotic prescriptions.
What steps has the Minister taken following the recommendations of the HPSC? Has she noted that the HPSC has also highlighted the lack of a specialist laboratory to determine the type of C. difficile? It is not a single threat as there are a number of different types. What steps are we taking to ensure that we have that laboratory expertise located here at home? There have been closures of several laboratories at a number of hospitals around the country and the HPSC's recommendation seems to fly in the face of what the Minister has been doing heretofore. Is she prepared to abandon that position and put in place proper laboratories that will give that critical service to our acute hospital system?
I listened to the Minister's comments on overcrowding I offer no apology for going back to a home base in relation to this. We are on the eve of what is proposed to be the transfer of all the remaining acute medical services at Monaghan General Hospital to Cavan General Hospital, which has been signalled to take place before the end of next month. How can the Minister rationalise what she said earlier about the challenges of overcrowding and hospital acquired infections with a proposal to displace 3,000 medical inpatient admissions annually to a hospital site that already has a 160% bed occupancy level? Surely, by any standard, this is an impossible project and it is placing people in ever greater danger, not only due to the increased possibility of contracting C. difficile, MRSA and all the other hospital acquired infections, but also because there is a raft of other health concerns. Surely we should not proceed with this under these circumstances.
There are five hospitals in the region and one third of their medical patients come to Dublin hospitals while half their surgical patients do so, which is an extraordinary statistic. Notwithstanding that, a person living in the north east is twice as likely to end up in hospital than in any other part of the country. There does not seem to be any reason for that. Whatever we are trying to do, best practice is involved. Sometimes we are in hospital unnecessarily, which is why it is so important to build up the community and primary care service around the country, where 95% of our health needs can be met. We have taken the advice of the expertise, specifically for new buildings. That is why the new children's hospital will consist of single rooms, as will the new site at St. Vincent's Hospital. That is the future.
With such a fragmented system, it was difficult to have the appropriate state-of-the-art laboratory facilities. It is about consolidating what we have rather than trying to put minor capital investments in all the various places and still not have the facilities we require. We listen to the expertise in this area. That is why I made C. difficile notifiable, and I accept that there are different strains, but that was only a couple of months ago. That was all based on the advice of the experts. We will soon have a new chief medical officer in the Department of Health and Children, as the position has been advertised. The current chief medical officer, Dr. Kiely, leaves today and I thank him for his service to the State. He is moving to the overseas development section of the Department of Foreign Affairs and I wish him well. The intention is that the new chief medical officer will head up the patient safety division within the Department, as heretofore the medical expertise was there on an advisory basis. That division will play an important role in giving the Government of the day appropriate advice on these issues.
The reduction in prescribing antibiotics is likely to be the major factor regarding MRSA, as the Minister said. However, the situation regarding C. difficile seems to be a lot more to do with conditions in hospitals, such as isolation and cleanliness. The Minister rightly ordered that C. difficile be a notifiable disease since last May. Is she not shocked by the figures? They show that from May to the end of August, there were 867 cases of C. difficile or associated diseases reported to the authorities, which is a very large number in just four months.
How can the Minister ensure that cleanliness is given the priority that is necessary in our hospitals? We have all heard stories about people cleaning hospitals who have to cover large areas in a short space of time and there can be slap-dash cleaning in clinical areas and other areas. Serious concern has been expressed by patients about the cleanliness of hospital toilets and so on. Will the microbiologists and others who have responsibility for cleanliness have enough clout to ensure that appropriate funding is provided within the budgets in straitened times to ensure that this is a top priority for our hospitals?
Until 13 September, there were 956 cases of C. difficile notified. As there was no notification before, we have nothing with which to compare these statistics. I do not think there is always a correlation between the money provided and the cleanliness of a hospital. Some of the hospitals that scored highest on the hygiene are those that have no microbiologist, such as Mallow hospital. Some of the older hospitals did well, as did some of the newer hospitals so there was no correlation between new buildings and old buildings, between hospitals with microbiologists and those with no microbiologists, or between in-house cleaning and outsourced cleaning. This must be a priority for the management of hospitals rather than microbiologists. We are entitled to expect at the least that our hospitals are the cleanest places in the country. When nuns were in charge of hospitals, my memory was of how clean they seemed to be. Therefore, I think this is a question of management rather than resources. When a hospital gets its budget, I expect its management to prioritise cleaning and hand washing.
I recently went to see a patient in St. Vincent's hospital and I was very impressed with the audio-reminder that reminded people to wash their hands. It was taken seriously by all the visitors to the hospital. I would love to see that approach in all the hospitals around the country, not just among visitors but also among the staff who work in those hospitals.
I get the impression from the Minister's replies that the concentration is on identifying when someone has an infection and then treating it. That is very important, but it is more important to ensure that people do not get the infection in the first place. I am always shocked to see health workers leaving hospital at 1 p.m. for their lunch or going out to do their shopping in their uniform and coming back on to the wards without changing uniform. Change is needed in this area. We can have all the alcohol scrubs we like, but there is an attitude that once the person attending the patient puts on sterile gloves, the patient is protected somehow. It protects the person, but not the patient.
We need to give patients the courage to question those who are treating them because at the end of the day people are afraid to ask professionals if they washed their hands, even though their treatment will depend on that person. If nurses do not have a place to change their uniforms and if they are supposed to wash their own uniforms at home, we cannot expect the type of control that is necessary to ensure that infection does not occur in the first place.
What measurement of infections takes place in psychiatric hospitals? What action has been taken?
I will answer Deputy Neville's question first if that is in order. Hygiene standards must be implemented in all health care settings, such as in the community setting and in residential settings caring for older people, children, individuals with a disability and the psychiatric setting. This is the intention in terms of the independent inspectorate from HIQA but it has not yet happened. I repeat what I said earlier that it is a matter for the management in all health care settings, whether in the psychiatric or the acute setting, to ensure the highest possible standards of hygiene apply.
In answer to Deputy Lynch's question, I do not wish to suffer from the big brother syndrome of telling health care staff when and where they can wear their uniforms but there is merit in what Deputy Lynch has said. It certainly would not be tolerated in other sectors of the economy for somebody working in a microchip plant or in the food sector to wear his or her uniform when travelling to and from work. We all have a significant role to play in this regard. There must be a focus on this area on the part of health care professionals, patients and the public. The patient of the future will ask whether health care staff have washed their hands but that time is quite a bit away, in my view.
Deputy Shatter has been offering for a long time.
Would the Minister agree that 956 instances of C. difficile recorded between May and this date, is a frightening number? Does she have available to the House the number of persons so recorded who have died either as a consequence of having C. difficile or whose death has been related to it? Can she confirm that in September at least two patients in Beaumont Hospital died as a consequence of having contracted C. difficile? Can the Minister also confirm to the House that as of this date, there are in excess of 100 claims taken against the State for damages by persons who contracted MRSA or by their bereaved family members and that these are being dealt with by the State Claims Agency? It has been estimated there could be up to 1,500 such claims and that the State Claims Agency has estimated that if the court proceedings prove successful, there could be a State liability in the region of €500 million. Would the Minister agree that in the interest of patient safety there is an urgent need to take a more dynamic approach to this issue and in the context of the State finances it makes more sense to spend this sort of money on cleaning our hospitals and addressing this issue in a more comprehensive way than having to pay it by way of compensation claims to bereaved relatives and those whose lives have been blighted?
Cases of litigation are always being taken against the health service and those matters are now managed by the State Claims Agency. Because we have enterprise liability I will not speculate on the outcome as this will depend on whether the State was liable. In the short term we can implement an approach based on hygiene which is what has been done. The most significant action would be to reduce the incidence of prescribing antibiotics but this cannot be done quickly; it needs to be accomplished over a period of time. The countries with the best record are those with much lower levels of antibiotic prescribing. As I said in reply to the Deputy's earlier question, one in three persons is a carrier of MRSA. The infection is often a contributory factor to death in some cases but more often than not, it is not the main cause of death——
What about C. difficile?
The C. difficile infection is new and I cannot give the statistics on how we compare with other countries because we only commenced measuring its incidence on 4 May last and it is a new measurement. It is important we do not ——
People are dying in hospitals.
I remind the Deputy that half of all those who die in the country die in hospitals and this is the case in every other country. We have always had——
They do not have to die. They have contracted C. difficile in hospital.
——what was known as the hospital bug. There are now names on these different infectious diseases acquired as a result of health care. The challenge for us is to have the expertise and the infrastructure to deal with them. The hospital of the future will be the single-bed model and this is what will pertain in the new children's hospital and in the new St. Vincent's Hospital. We have much to do in terms of infrastructure and in the areas of hand washing, infection control and antibiotic prescribing. We have a multifaceted approach which I believe is working. The reduction of 20% over the next four years is a challenging target which I believe we can meet.
That completes questions to the Minister for Health and Children. Under the order of the Dáil of this day, we must now proceed to Leaders' Questions.
Written Answers follow Adjournment Debate.
