TRANSPARENCY for EQUAL ACCOUNTABILITY in MEDICINE

November 2, 2007

SLAYING THE NHS SUPERBUGS – Mind the Dif!

         It is very alarming to hear about the problems NHS Hospitals are experiencing in dealing with “Superbugs;” this is very worrying on top of all the threats of curtailed local A&E and Maternity services.  These two problems might not at first appear related in any way, but in reality they both stem from the inappropriate squandering of Government funding.  Through this Internet Blog I have been very outspoken with regard to exposing factors that have exacerbated similar problems in US Hospitals, notably  what I call the “Deliberate Negligent Understaffing”  of Medical facilities that prompted me to create the “C.U.T!” Campaign to “CONTROL UNDERSTAFFING TODAY.” 

        Both my family and I have always received an impeccable level of service and exemplary care from the NHS.  It is hard for me to talk with any real authority about the inner workings of the British system as I do not work in the NHS, but from what I have been told a disturbingly similar pattern has emerged here in the UK.  I have several close family members and friends working within the NHS at various UK Hospitals and it certainly appears that the NHS is eagerly following the disastrous US model for bloated top heavy Management and understaffing of basic care providers, Nursing and cleaning staff.  Ultimately the NHS is hemorrhaging money on those high wage earners in Management, but instead of addressing the real problem the Government orders a restructuring of essential services to reduce local access to care.   We all know that even if this crazy strategy was clinically justifiable those infamous “Super Centers” would still be ham-strung with the same budgetary constraints caused by top heavy Management.

Fact:    in Healthcare you cannot do more with less! 

        It is simply ludicrous to try and pretend that Government targets don’t impact the NHS Trust’s ability to deliver quality care. All initiatives that generate paperwork require additional administrative staff to handle the paperwork; this is an unfortunate fact of life. “Targets” might look good on paper, but the issue is that there is far too much paper and the burden of managing that excessive quantity of paperwork is sinking the ship.  The consequences have a powerful impact on the staffing budget within the NHS, as financial resources must be diverted to cover the cost of those administrative personnel often at the expense of Nursing and cleaning staff.  You just cannot do more with less.  Fewer Nurses mean less bedside care and less stringent supervision of assistive personnel; fewer cleaning staff mean lower levels of sanitation that allow Superbugs to thrive on unclean surfaces.

           The use of contract cleaners might at first appear to save money, but this has introduced an entire workforce of minimum wage earners who are not in the least bit invested in maintaining safe, hygienic patient care and are not trained in medical grade cleaning. Meanwhile money is squandered on unnecessary contract commission fees.  Staffing constraints have been eroding the quality of Nursing too with the ratio of Agency temps steadily on the rise.  Although the Agency Nurses are often highly qualified they will always be at a disadvantage in the workplace.  They may not know where essential items are kept plus they are unfamiliar with their coworkers and the hierarchy of responsibility among other staff. It is unreasonable to expect stringent supervision of unfamiliar assistive personnel from an Agency Nurse hired by the shift!  This is one reason that cleaning standards have seriously deteriorated.  Bring back Matron! The NHS has recently made a commitment to increase the number of Matrons, a very wise decision.  Any money paid to outside contractors or Nursing Agencies reduces the cash available to pay directly to staff and reduces both the number of staff and the quality of their commitment to their job. 

      From an employment perspective Hospitals require 24/7 staff coverage so the necessity for flexible working hours already exists; this is ideal with regard to additional obligations, study or internal training. Entry level jobs in Healthcare offer a unique opportunity for unqualified school leavers and unskilled Job Seekers to obtain employment that can lead to potential on-the-job training. This investment in internal training schemes should become a new NHS priority as it creates a powerful incentive to do quality work to be considered for further training and job advancement.  This will promote a genuine pride and commitment from employees that outstrips the miniscule savings of cheap high turnover contract laborers. 

       While New Labor proudly touts the money that has been pumped into the NHS, far too much has been squandered on bloated administration costs, increasingly top heavy Management and expensive consultancy or commission fees.  What really outrages the public is when an obscene payout is obtained by a departing Manager who has been removed or forced to resign due to a public outcry over their gross incompetence! Departure bonuses are adding insult to injury, especially at Hospitals like the Conquest in Hastings that was threatened with closure of the A&E and reduced Maternity services just as a former head Manager left with a huge payout.   

     

HOSPITAL ACQUIRED (NOSOCOMIAL) INFECTIONS

Nosocomial Infections can Result from the following Causes

BREACHES OF INFECTION CONTROL PRACTICES:                         e.g.   Improper hand washing or a reluctance to use gloves on all occasions.

BREACHES IN STERILE PROCEDURES:                                        e.g.   Improper donning of sterile gloves for minor procedures like the insertion of a Foley Catheter.

INADEQUATE CLEANING OF ALL ENVIRONMENTAL SURFACES:     e.g.   Less obvious targets may get ignored in the rush; this often includes Computer keyboards and phones.

IMPROPER STERILIZATION OR INSTRUMENTS AND EQUIPMENT:   e.g.   Autoclave sterilization of Instruments provides for stricter controls than Bronchoscopes or larger items of equipment like an operative microscope or a C-Arm.

HOSPITAL STAFF WHO COME TO WORK WHEN THEY ARE SICK:   e.g.   Unfortunately, this is alarmingly common in the US where staff are actually penalized for calling in sick! I do not know if this disastrous tactic has been implemented or even considered yet by the NHS, but it is a very bad policy.

      It is overly simplistic and insulting to blame the current sharp rise in the infection rates on lazy, careless Nursing staff, improper hand washing or a reluctance to use gloves on all occasions.  Medical staff need enough time to ensure that simple routine practices do not get ignored in the rush, while cleaning staff need training, supervision, and motivation as well as adequate time to do a thorough job.  Management have become so focused on doing more with less that the overstretched regular staff have no opportunity to do their job diligently and this has resulted in the increased infection rates and a higher incidence of unnecessary Medical errors.

        One disingenuous initiative required staff to wear special buttons with the words: “Ask me if I have washed my Hands?”  Nurses resent these top down campaigns, and rightly so, because they consistently ignore the single most important issue: lack of time due to understaffing.  In reality it would be more appropriate for the buttons to say: “Ask me if I had time to wash my Hands?”   While Deliberate Negligent Understaffing is ignored Nurses remain so overstretched and overworked they barely have the time to run to the toilet, so how are they expected to prioritize routine infection control practices?         

        One example of sterility botched in the rush, is the fairly common procedure for donning sterile gloves prior to Foley Catheter insertion.  Inadvertent contamination is only avoided be strict adherence to Sterile procedure in order to prevent Urinary Tract Infections, UTIs.  There is far more likelihood of contamination when Nurses are in a tearing hurry or distracted by a multitude of other duties that demand attention.  This has resulted in an increase in the number of Urinary Tract Infections among Hospital patients; an unnecessary consequence of inattention to sterile procedure. In the US the ongoing expenses related to avoidable infections that are caused by procedural errors or acquired during treatment, including UTIs, are on a list of targeted billing charges that will no longer be covered my Medicare. Time is an important factor in reducing these unnecessary infections, but Management are still putting the squeeze on Nurses and disciplining them for the inevitable lapses that result from overwork.  Patients left in soiled bedding for hours on end or not turned to reduce the chance of bedsores; all these oversights are unfairly blamed on “lazy Nurses” who have no say over the chronic understaffing of clinical areas.

          Although there are still a few stubborn old-timers who insist they cannot start an IV while wearing gloves, on the whole compliance with universal precautions is getting much better.  However, the real danger is when gloves worn during a procedure are not promptly removed as soon as the patient contact is finished.  It is pointless telling staff they shouldn’t do this if the reality of severe time constraints and their excessive workload make such lapses inevitable.  Computer keyboards and phones have become the unconscious magnate for bacteria because overworked Medical staff will frequently go directly from the patient to the documentation point or phone without removing contaminated gloves.  This carries bacteria from the patient to a place that is generally ignored by cleaning staff.  Contract cleaners or untrained entry level cleaning staff tend to focus on just the visible dirt if they are not specifically taught about the transmission of bacteria on work surfaces.  These staff need more comprehensive training, so that they fully understand the significance of what they are asked to do and how they are expected to do their job. 

         A Nursing assistant cleaning the OR (Operating Theatre) might not understand the infection risk presented by a fly within the Sterile Core.  But, something as miniscule as a fly can still transport bacteria from Fido’s last poop to the sterile instruments in Surgery!  Untrained cleaning staff might not understand why infected material must be removed promptly from the OR (Theatre) or why containers for hazardous waste must be confined to the Hopper Room.  They may think that this stipulation is just a petty Hospital rule, but it is the responsibility of the Hospital to train cleaning staff properly and supervise their work.  When these staff do not make the connection between the full to overflowing dumpster left in the hall way alongside a piece of equipment like a C-Arm that will go into Surgery we risk life and limb.  That C-Arm could be used during a case where the insertion of an orthopedic implant would make the patient highly vulnerable to a very serious risk of infection.  Ignorance, inadequate supervision and poor Management is no excuse for the unnecessary infection or potential amputation that could result from a seemingly unrelated oversight like this. 

        Agency Nurses who do identify problems with compliance in the facilities they are assigned to on a purely temporary basis might not know who is responsible for assistive staff or getting clean up taken care of.  Agency staff are only working because too few regular staff are on duty, so who is responsible?  Agency staff unwittingly provide a convenient scapegoat; when things go wrong it is easy to divert the blame away from regular employees or Managerial incompetence. While oversight remains minimal, genuine accountability is in jeopardy.  All too often potentially serious infection control incidents are overlooked in the hectic pace of shift work, but this situation is exacerbated by reducing the number of regular, full time staff.  All Medical facility cleaning staff need proper supervision to insure they are doing a proper, thorough job and providing Hospital standard levels of sanitation, however expecting overstretched Nursing staff or Agency temps to keep an eye on them during their frenetic working day is expecting the impossible.  Ultimately, Management is responsible for making sure that there are enough regular trained staff on duty in their clinical area for every shift.  When they understaff an area for financial reasons they risk the disastrous consequences of unnecessary infections and serious Medical errors.

      The above examples refer to incidents observed in US Hospitals, but they could just as easily occur in NHS facilities. In the US the drive to cut costs with Deliberate Negligent Understaffing of clinical areas has seriously backfired with the increase of Hospital acquired (Nosocomial) infections that often require prolonged Hospitalization and cancel out any savings benefit.  Another disastrous strategy was to penalize staff for calling in sick.  Each time someone calls in sick it is considered a separate “Occurrence,” but more than three such “Occurrences” in the same calendar year place an employee in the disciplinary process requiring counseling by a Nurse Manager.   The “Occurrence” policy was introduced to discourage unnecessary absenteeism, but has resulted in sick staff treating very sick vulnerable patients and placing those patients at increased risk.  A serious outbreak of a virulent new strain of virus could gain a serious stranglehold on the US Healthcare industry before inoculation ever really got underway, because sick  Hospital workers would still feel compelled to come to work. In America this deeply flawed policy has created yet another weakness in a society with a myopic focus on money.

        Can a Nurse with a raging migraine headache really cope with a dozen screaming newborns as the American TV advert for one medication suggests?  Does this disastrous policy provide safe patient care or just larger profit margins by reducing sick pay?  Someone with a really bad cold should not be working in Surgery, especially treating cancer patients who have lowered immunity.  Despite violating well established protocol guidelines for managing infection risk among those who scrub into Surgery, US Hospitals adhere to a dangerous policy that forces sick staff to show up for work in the OR.  Worse still when Surgical staff all cram into an overcrowded locker room to change into scrubs they pass their germs on to multiple other coworkers. Management still think that treating illness as an unnaceptable conduct offence to be disciplined, rather than an infection risk to be avoided, is a great way to lower absenteeism and save money! 

     I do not know if similar warped sickness call in policies are used within the NHS, but it seems that whenever US Healthcare comes up with a disastrous idea, Britain rushes to emulate their mistake.  The 21 points that I identified in the list of priorities to CONTROL UNDERSTAFFING TODAY certainly include all of these issues that affect our ability to fight infection in Medical facilities.  I can only hope that if this set of priorities becomes part of US legislation, the NHS will be just as eager to rapidly take these issues seriously.  I would like to encourage British readers familiar with the NHS to comment here on the points I have made.  I would welcome a more informed contribution from someone more familiar with working here within the NHS.

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