14 February 2007
Dr. Henry: I thank Senator Glynn for his kind words on exactly the area I wish to address. I welcome the Minister for Health and Children, Deputy Harney, to the House. I have frequently heard her speak on this issue and am well aware that she realises its seriousness. Florence Nightingale said that when the sick enter hospital, they should not become sicker as a result. We have got into an unfortunate situation where people going into hospital are very afraid that they will become infected by antibiotic resistant bacteria and that it will be the end of them. However, thanks to my friend, Dr. Fred Faulkner, the chief microbiologist at St. James's Hospital, I have a report from the standing medical advisory committee to the Department of Health in London. It was written in 1959 and addresses staphylococcal infections in hospitals and antibiotic resistance. We are not dealing with a new problem but with one that has now got seriously out of hand.
If the Minister read this report, she would find that many of the summary conclusions and recommendations are exactly the same as our own. The first is that the control of staphylococcal disease depends largely on the application of aseptic methods, in other words, cleaning up. The use of antibiotics, either for treatment or for prophylaxis, is by itself unreliable. We have a terrible idea nowadays that there is a pill for every ill and that we can solve everything that way. The area I wish to address is the seventh recommendation, namely, that in all suspected cases of staphylococcal disease, it is desirable to confirm the diagnosis by bacteriological investigation. We have not put enough emphasis or exerted enough effort on this situation.
Initially we had bacteria resistant to one antibiotic. MRSA initially stood for methicillin resistant staphylococcus aureus. However, MRSA rapidly became multiply resistant staphylococcus aureus, and the current situation is that we have not just staphylococcus aureus but many other bacteria resistant to the most common antibiotics, with nothing else coming down the line to take over from them.
Bacteria have been here for billions of years. They are far more successful than human beings, who have been around only for a few million years.
Mr. Ryan: They are tougher too.
Dr. Henry: They are a great success, managing to change their little jackets overnight so that whatever affected them yesterday has no effect on them today. New antibiotics are being introduced only to be defeated within a few days. We have not put enough emphasis on the role of the laboratory, which can be the key to diagnosis and surveillance in acute hospitals in particular. We must know what the mechanisms are in these changing bacteria so that we might have some idea of the best way to make progress. Only in the laboratory will we manage to find out anything about suitable prescribing, in the hospital and outside.
I very much regret that 100% of our cervical smear tests now go to Dallas in the United States, since it has a terrible effect on morale in Irish laboratories conducting such screening. What will happen to the training of medical scientists if we outsource all our specimens? The international privatisation of specimens from hospitals would be a terrible mistake and I hope that the Minister can rectify that problem as soon as possible.
The resistance of many bacteria is probably under-diagnosed owing to insufficient surveillance in hospitals, never mind what is happening in the community where we frequently have very little idea what is occurring. There have been cases where we do not know what mechanism caused the bacteria to change and we must know that because genes coded for resistance emerge in one strain only to be transferred to others. That DNA change means that various mechanisms can be used by the bacteria to defeat an antibiotic.
That can make a difference to how one directs one's next line of treatment. For example, if the enzyme b-lactase is produced, it breaks down the b-lactam ring in penicillin, and that is the anti-bacterial part. If one knows that the bacterium is using that mechanism, one will not try a cephalosporin since the same thing will happen, moving on instead to a different type of antibiotic such as a tetracycline.
This can also happen with gram-negative bacteria, including e.coli, and there are other methods that the bacteria can use, such as altering the penicillin's binding proteins so that it cannot work. One needs to know exactly what they are doing, and our laboratories are not receiving sufficient investment in the area. It must be done countrywide and not just in research laboratories. It is terribly important that we get at it as quickly as possible if the problem of multiple drug resistance is not to worsen further.
It is only if we take such steps that microbiologists will be able to advise surgeons, physicians and junior hospital doctors of the next best antibiotic rather than allowing the scattergun approach seen in far too many hospitals. Part of our problem is that medical scientists are not being encouraged enough or given enough finance to investigate the area.
Senator Glynn noted that I raise this constantly, and I heard the Minister speak on it on the radio, namely, the education of the public into desiring antibiotics where they are not strictly necessary. I see from the text of the amendment that the Government parties acknowledge the upcoming television and radio campaigns to increase awareness of the importance of hand hygiene among hospital staff, visitors and patients. What about a campaign on expectation and the feeling that if one visits a general practitioner and does not come away with a prescription for an antibiotic, the consultation has been a failure? Most upper respiratory tract infections are viral and many of the pneumococci are resistant to antibiotics, yet 40% of antibiotic prescriptions are for upper respiratory tract infections.
The Government must invest in educating not only the public but GPs and hospital doctors. Pharmaceutical companies are now relied on to hold medical seminars and so forth, but they will hardly suggest that people cut down their use of antibiotics. The Government will have to get involved and carry out trials of different treatments. One would be as well to put one's head over a bowl of friar's balsam and inhaling. The Government must get involved in such trials because no one else will be able to do so. Antibacterial wipes, which are advertised on television, are lethal and should not be allowed at all.
I must refer to the abuse of antibiotics in the food chain, particularly among poultry and pigs who are brought up in factory farms. Although these are called growth enhancers in their food, they are antibiotics. They may not be used by humans, but they are encouraging resistance among animals and poultry. There is far to casual an attitude about this and it should be discouraged.
This is a matter of surveillance and investment in our laboratories, and education of patients and doctors as to the appropriate use of antibiotics.
Minister for Health and Children (Ms Harney): I welcome the opportunity to make a statement in this House on MRSA. I reiterate my commitment to ensuring that high-quality care is made available to all patients and to the further development of our health services and, in particular, the issue of patient safety.
At the outset, I want to assure Senators that the vast majority of patients in Ireland receive effective and safe treatment. However, international studies suggest that a minority of patients can be harmed through their care, either in hospital or in the community. I do not wish to minimise in any way the effect on patients and their families of contracting infections in hospitals and other health care facilities, and I acknowledge and regret the pain caused to patients and their families. It is a problem in all health care systems but one which I am determined to control in the Irish health care system.
MRSA is not a new problem and it is unique to Ireland. Health care associated infections, HCAIs, including MRSA infection, are in many Irish hospitals and MRSA is increasingly being seen in community health care units such as nursing homes. The impact of these infections is considerable. At a human level the impact on patients and their families can be debilitating. It is in everybody's interest to keep infections out of our hospitals, out of nursing homes and out of all settings where people are vulnerable.
The control of health care associated infections, including MRSA, continues to be a priority for the Health Services Executive. Measures to control the emergence and spread of health care associated infections are necessary because there are fewer options available for the treatment of resistant infections, as Senator Henry acknowledged, and because these strains spread among vulnerable at-risk patients.
Acute hospitals collect information on health care associated infections at a local level. It is my intention that this information will be collected, both locally and at a national level. We need to be able to measure data and compare it.
Among the recommendations in the Strategy for Antimicrobial Resistance in Ireland is the appointment of infection control nurses, surveillance scientists and antibiotic pharmacists necessary to commence a national surveillance programme. The HSE is currently in the process of recruiting these staff and they should be in place in the coming weeks and months.
The HSE has appointed a small group, led by an assistant national director of health protection, to take the lead on MRSA. The group has concentrated on a targeted number of issues including the development of a three-year action plan and overseeing its implementation, as well as putting a high quality governance structure in place. It has always been my experience that if everybody is responsible then nobody is ultimately responsible. It is therefore vital that there is clarity around this issue.
There is an increasing body of evidence of what are the best and most effective practices to reduce the impact of HCAIs. The HSE will take measures including: a public education campaign; directed action on specific health care associated infections; initiatives on the appropriate prescribing of antibiotics, particularly working with general practitioners; a national surveillance system for HCAIs; a health care worker educational and training programme; and the implementation of a standardised approach to antimicrobial susceptibility testing.
A number of projects have been continued or started over the last year. These include recruitment of key staff including scientists, infection control nurses, antibiotic liaison pharmacists and surveillance scientists while good practice guidelines on control and prevention of MRSA. A hand-washing poster campaign, "Clean Hands Save Lives", took place in October 2005. I note that this campaign is not in operation in some health care settings I visit and that is a cause of considerable concern.
I acknowledge what has been stated here about other industries. In my previous job, where I had responsibility for visiting many settings including the semi-conductor and pharmaceutical sectors, the standard of hygiene required of visitors included covering hair, covering shoes and covering all clothing by wearing a white coat or other such garment. In vulnerable places in hospitals, particularly intensive care units and such areas, we need to learn quickly from what is happening in other sectors.
The projects to which I referred also include the following: antibiotic stewardship guidance to guide professionals on the appropriate use of antibiotics is being developed; existing systems on data collection on community and hospital antibiotic consumption are being enhanced to provide a more detailed and wider range of information on antibiotic prescribing while the HSE is planning to create a suite of education and training programmes on HCAIs for approximately 4,000 health care workers.
On the development of a public education programme, a two-year national publicity campaign on HCAIs and antibiotic resistance which will use the full range of media, at both national and local levels. On information for patients, the Health Protection Surveillance Centre has information for the public on HCAIs on its website. The HSE will ensure that the availability of this information is brought to the attention of all hospital managers and consultants. It will be made as widely available as possible within the hospital for distribution to patients and members of the public.
The HSE and the Department of Health and Children sponsored the Irish Patients' Association in organising a clean hospital summit in January 2006. This brought together over 200 HSE staff with a key role to play in promoting hospital hygiene in their workplace. A further summit is planned for the spring of this year.
I have met with representatives of the MRSA and Families group. It is a responsible group of citizens who have been badly affected, either directly or through their families, as a result of acquiring infections in a health care setting. The HSE has also held constructive meetings with them and further meetings and discussions are planned.
Visiting hours and associated problems with the influx of visitors has been seen as a possible complicating factor in maintaining hospital hygiene and in controlling infection. A national visiting guidelines document has been produced by the HSE. I would ask all visitors to hospitals, in so far as is possible, to respect hospital visiting times and also to be vigilant in using the facilities available to ensure that their hands are not carrying infection to patients.
A project plan for the development of a GP educational initiative to run from early this year until 2009 has been developed. This will include the recruitment of 20 continuing medical education groups, the establishment of a surveillance system on antibiotic prescribing and the development of guidelines and the education of GPs.
It is difficult to identify the number of fatalities attributable to MRSA as many people also have significant co-morbidity factors. Last year Ireland participated in the Hospital Infection Society's "Prevalence Survey of Health Care Associated Infections" in the United Kingdom and Ireland. The survey provided accurate and comparable data on the prevalence of health care associated infections, including MRSA, in acute hospitals in Ireland and can also be compared with similar data being obtained in England, Scotland, Wales and Northern Ireland. Preliminary results of this study are now available and the final results will be available shortly. The overall prevalence of health care associated infection in the UK and Ireland study - these figures exclude Scotland - is 7.9%. The figures are 8.2% for England, 6.3% for Wales, 5.5% for Northern Ireland, and 4.9% for the Republic of Ireland.
As I mentioned earlier, the prudent use of antibiotics underpins any approach to the control of antibiotic-resistant bacteria, including MRSA. This, together with good professional practice and routine infection control precautions, such as hand hygiene, constitute the major measure in controlling and preventing health care associated infection, including that caused by MRSA, both in hospital and in community health care units.
Hospital cleanliness is also vital in fighting the spread of HCAIs. To date, two national hygiene audits have been carried out in acute hospitals. The first audit was carried out in mid-2005. The second audit was conducted in early 2006. The results of the second audit showed that significant work had been done at hospital and national level. Almost every hospital had increased its overall score since the first audit, with some of the most significant improvements being shown by those hospitals that recorded poor scores in the first audit.
A national cleaning manual has been issued to support hospitals in maintaining good hygiene and the Irish Health Services Accreditation Board, IHSAB, is due to carry out a third hygiene audit this year. Well managed hospitals will be ready at any stage for an audit.
The board also developed the hygiene services assessment scheme at my request. This was officially launched in November 2006 and is a four stage process involving self-assessment, peer review, award and report. The IHSAB initiated the self-assessment process in all acute hospitals in January with the peer review visits commencing in April and the final report in August 2007. The ethos behind this type of scheme is that for hygiene to become an inherent part of daily operations within a hospital staff must take ownership of the process and self assessment is the driving tool to do this.
All medical practitioners have an ethical responsibility to complete death certificates as accurately as possible and this includes recording methicillin resistant staphylococcus aureus, MRSA, infection. The attending doctor must sign the death certificate and determine cause of death. In November 2006, a coroner's court recorded what is believed to be the State's first verdict of death by MRSA infection. The coroner ordered that deaths due to hospital infections must be reported to the coroner and other reporting bodies so that statistics could be gathered. This is the first time this has occurred in Ireland and members of the central council representing the families involved have welcomed the ruling and I share their response.
Last month, I welcomed the announcement by the Health Research Board, HRB, of the establishment of a multi-disciplinary research team that will investigate and help tackle health care associated infections. The research will look at three specific areas: enhanced cleaning processes and their impact on infections, the clinical usefulness of the rapid detection of MRSA and more intensive efforts to improve hand hygiene to achieve near 100% compliance with best practice.
The HRB funded research team will then use state of the art molecular technology to determine the relationship between environmental contamination with health care associated infections and the incidence of such infections.
The organisation of health services is complex in any country and for any population. As in any large organisation, this complexity challenges us to find a radical simplicity that guides our work and decisions. Many procedures are in place to protect the well-being of patients and to secure the best medical outcome possible, however, as with any system, these safeguards are not completely error proof. I would like all of us in health care to unify around one very basic promise to patients before all else, namely, that they will be safe. I would like this simple promise to drive everything it possibly can in health care - policy, practice, organisation of hospitals, organisation in hospitals, individual and group behaviour, resource allocation, recruitment, training and education. There is virtually no area of health care that a patient safety agenda cannot and will not positively influence.
A modern health care system accepts that each person can play a central role in his or her own treatment and recovery. It recognises that each individual plays a critical and essential role in the assessment of his or her own needs and that quality of care is inextricably linked to the involvement of the user in determining his or her health care.
Patients and their advocates must be also encouraged to play their part in embedding safe care in our systems. Patients, their relatives and carers must be central to our efforts to minimise harm and we must develop mechanisms which empower them to point out any possible errors or care deficiency without fear of the consequences.
To this end I have asked the Health Service Executive, HSE, to set up a national help line which patients and their families can call to report incidents of poor infection control in our hospitals. If, for example, patients are unhappy that a member of the hospital staff is not disinfecting his or her hands between patients, they or a family member can call the helpline if they do not feel in a position to raise the matter directly with staff in the hospital. This is not about blaming people, it is about helping all of us, patients, visitors and health care staff, to play our part in improving patient care.
In addition, I recently established a Commission on Patient Safety and Quality Assurance. Membership of the commission is made up of medical and nursing representatives, management representatives and representatives of patients and carers. The overall objective of the commission is to develop clear and practical recommendations to ensure that quality and safety of care for patients is paramount within the health care system.
The commission will develop proposals for ensuring clear responsibility, among senior management and clinical leaders within the health system, for performance in relation to quality and patient safety. It will also make recommendations on more effective reporting of adverse clinical events and complaints and a clearer role for patients and carers in feeding back on care received. It is intended that the commission will report back within 18 months.
Finally, I would like to refer to the importance of the establishment of the independent health information and quality authority to progress the safety and quality agenda. This is provided for in the Health Bill 2006, which I hope this House will have the opportunity to debate in a matter of weeks.
In 2005 I reaffirmed Ireland's commitment to enhancing the safety of patients by signing up to the Global Patient Safety Challenge. This is a major initiative, undertaken by the World Health Organisation, WHO, which aims to address significant aspects of risk to patients receiving health care. During 2006 and 2007, the Global Patient Safety Challenge will be to identify, develop, test and evaluate strategies for the implementation of the WHO guidelines designed to assist countries in improving patient safety and saving lives by reducing the burden of health care associated infections.
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