This blog has written many times of the damaging effects that targets and excessive top-down instruction has had on patient care by distorting clinical priorities and removing patient focus. It is also something the Healthcare Commission has reported many times, and yet again today.
A report released in July this year found some 45% of the 155 NHS Trusts the Healthcare Commission surveyed reported that waiting time targets for treating patients in A&E were putting infection control measures at risk.
A year ago the it found the outbreak of C. difficile at Stoke Mandeville Hospital to be at least partly attributable to “the approach to the target for A&E [which] led to some patients with infections being admitted to, or moved to, open wards rather than isolation facilities”.
And again today, their investigation into the 1,170 outbreaks of C. difficile at Maidstone and Tunbridge Wells NHS Trust between April 2004 and September 2006, which killed an estimated 90 patients, reached a similar conclusion:
“The infection control team was keen to isolate patients with C. difficile but the scarcity of side rooms made this difficult…it took four months to establish an isolation ward exclusively for patients with C. difficile. In our view this was partly because of the pressure on beds and the trust’s desire to meet targets.” (p.4)
It also made a point of drawing on similarities between the findings of its investigation here and that previously mentioned at Stoke Mandeville Hospital, noting that:
“While it should be noted that improvements have subsequently been made at Stoke Mandeville, it seems unlikely that these similarities are coincidental. We are concerned that where trusts are struggling with a number of problems that consume senior managers’ time, and are under severe pressure to meet targets relating to finance and access, concern for infection control may be undermined.” (p.9)
The list of failures relating to infection control at Maidstone and Tunbridge Wells NHS Trust is, quite frankly, shocking:
• Despite the fact that the monthly number of new patients with C. difficile doubled between October and December 2005, the trust failed to identify the outbreak at the time. A further 258 patients contracted C. difficile in a second outbreak from April to September 2006.
• The trust had not put in place appropriate measures to manage and prevent infection, despite having high rates of C. difficile over several years. Neither did its board spend enough time considering issues relating to infection control.
• The board did not address problems consistently raised by patients and staff, such as a shortage of nurses, poor care for patients and poor processes for managing the movement of patients from one ward to another, all of which contributed to the risk of spreading the infection.
• Patients were often moved between several different wards, increasing the spread of infection.
• On medical wards rates of bed occupancy averaged over 90% and in some cases were more than 100%, meaning that the trust had to open up special “escalation areas” to accommodate extra patients. This high turnover of patients limited the time available to clean beds between patients.
• Many of policies adopted for preventing and managing infection were out-of-date or not easily available to staff on the wards.
• Nurses were often too rushed to clean their hands properly, empty and clean commodes, clean mattresses and equipment properly and wear aprons and gloves appropriately and consistently.
• There was evidence of several occasions when nurses told patients to “go in their beds”, rather than assisting patients with diarrhoea to a commode or bathroom.
Typically, the Health Secretary, Alan Johnson, said he was shocked by the findings, but denied accusations that the problems were caused by staff being put under pressures to meet government targets. Of course, it would be folly to suggest all the failings can be attributed to this, but the Healthcare Commission is not an organisation that deals in critiquing government policy. If their investigations have led them to feel strongly enough to highlight it time and time again, the government should start to listen. Targets don't work.