How to wash out NHS super bugs

You put your left hand in,

You put your left hand out,

Touch another patient

And you spread the bugs about.

OK, so they may not be the greatest lyrics in the world, but the jingle on the poster tacked to a wall near the entrance to York Hospital's Ward 35 gets the message across. Nearby is an alcoholic gel dispenser - and above it a sign saying: "Visitors are encouraged to use the handwashing facilities before and after visits."

Hospital hygiene has become a hot issue, partly because of headlines such as that in yesterday's Daily Mail. "One in 11 hit by superbugs", it screamed, above a story asserting that one out of every 11 hospital patients would pick up an infection.

And that's not just media scaremongering. Hospital chiefs would fiercely dispute any suggestion that one in 11 hospital patients risk picking up a life-threatening infection as a result of their hospital stay. But they do admit they "took their eye off the ball" when it came to hygiene and infection control.

Alan Maynard, the chairman of York Hospitals Trust, recalls a conversation he had with his mother-in-law shortly before her death seven years ago. She had been a nurse in the 1930s and was "appalled" at the standards of hygiene in many modern hospitals.

In her day, the washing of hands was de rigueur. But over the years, overworked hospital staff let their standards slip.

Why? Antibiotics, says York Hospital's chief operating officer Mike Proctor. The belief that you could kill off any unwanted infection by using antibiotics bred complacency. "Clinicians, nurses, physicians, all took their collective eye off the ball."

It came back to haunt them. The overuse of antibiotics led to the development of resistant strains of bacteria, among them the so-called "superbug", MRSA. And the widespread use of "broad spectrum" antibiotics - a scattergun approach which used antibiotics effective against a wide range of bacteria, good and bad, to try to wipe them all out - played right into MRSA's hands. Because it was resistant, it survived and flourished once doctors had killed off the bacterial competition.

Over the past few years, hospital chiefs have begun to wake up. There is now much more emphasis on hygiene and doctors are much more careful about prescribing antibiotics.

In many ways, York Hospital is ahead of the game. It has already strengthened its infection control team from a single part-timer ten years ago to three full-time posts.

Last year the hospital piloted a "clean hands" campaign on several wards, a campaign that has now been rolled out to every ward. Early next year, it will ditch the contract cleaners who now keep wards clean, and bring the job in-house - almost doubling spending on cleaning at the same time, from £1.2m to £2m a year.

It is obvious, with hindsight, that the privatisation of hospital cleaning in the 1980s was a backwards step, says Mr Proctor. "It drove down costs, and at the same time it drove down quality." The hospital is at last going to put that right.

Already, you can see the changes brought about by the new attitudes towards hygiene. Signs and posters reminding people to wash their hands are everywhere - at the entrances to wards, outside loos, on hospital corridors. Alcoholic gel dispensers have sprouted all over the hospital. They, too, are outside every ward, in every corridor - and, most crucially, at the side of every patient's bed.

The idea is for every member of staff - nurse, technician, junior doctor or even consultant - to wash their hands every time they enter and leave a ward, and each time they have seen one patient and before they go to the next.

There is no excuse not to do so, says Sister Tracey Ward, who is in charge of Ward 16. The alcoholic gel is easy to use - you squirt it on from a wall dispenser, rub your hands, and because it is alcohol based, it dries itself. The alcohol kills germs stone dead and because there are so many dispensers, you never have far to go to get a squirt of gel.

"There's an old saying that you're never more than 12 feet from a rat," says Tracey. "Well, in this hospital you're never more than 12 feet from a hand gel!"

For most staff members, the gel has already become second nature. It is already paying dividends, says Prof Maynard: infection rates at the hospital are on the way down.

There are still those who occasionally forget to wash their hands between patients. It is usually doctors, rather than nurses. "The nurses are better," admits Tina Hardy, Ward 35's resident housekeeper. "The consultants and doctors sometimes just need that little bit of a gee up."

If she spots such an errant doctor, she administers a gentle touch on the arm followed by a quiet reminder "you haven't washed your hands". It is important to do it in a nice way, she says.

Another part of the hospital's strategy is encouraging patients to ask medical staff whether they have washed their hands. Yet another poster tacked to the wall in ward 35 bears the legend: "It's OK to ask staff and doctors 'have you washed your hands?'"

"Sometimes patients are afraid to ask," says Tina. "But they shouldn't be. Each and every patient has their own gel dispenser beside their bed, and there is no excuse for anyone to forget."

The approach seems to be working. John McBlane, 36, recovering in ward 16 from an operation on an abscess, is impressed. Patients on his general surgical ward are among the hospital's most vulnerable because they are recovering from major operations.

Operations leave wounds and bacteria usually carried on the skin can get into the blood through the wound and cause an infection. As many as 30 per cent of people carry Staphylococcus Aureus, a bacterium related to MRSA, around with them on their skin, says Alan Maynard. Normally it is perfectly harmless. It is only when MRSA, a mutated version of the bug, gets into the bloodstream through a wound or cut that it causes problems.

Particular care is therefore taken on wards such as John's and he fully appreciates it. "It is reassuring," he says.

Doctors and nurses are not the only people who can spread germs in a hospital. Patients and visitors can too. Very often, Prof Maynard says, MRSA is brought into hospital by patients or by their visitors.

That is why it is vital visitors and patients wash their hands regularly too while they are in hospital, to help avoid the spread of bugs.

It is important everywhere in the hospital - but nowhere more so than on the maternity wards, says Alan Maynard. When a new baby is born, there is nothing more natural than for doting uncles, aunts and grandparents to want to pass the child from person to person "like a little rugby ball".

There is nothing wrong with that - except that if visitors don't wash their hands and one of them has bacteria on their skin, they could easily spread it around. "And then the mother gets the little baby to suck its thumb, and you've got an infection," says Prof Maynard.

The alcohol gel dispensers around the hospital are for patients and visitors as much as staff. Don't forget that, next time you are visiting the hospital. Their health is in your hands.

Code warning

Hygiene standards at hospitals such as York could get even more stringent later this year, when the new NHS Hygiene Code comes into force. Nobody yet knows what the code will say, but it is expected to raise hygiene standards for all hospitals and care homes.

Prof Maynard believes the code may require the NHS to learn lessons on cleanliness from private sector companies such as Nestl - which he visited with Mike Proctor a few years ago.

Will hospital staff have to wear hair nets? Unlikely, he thinks. In fact, he believes the new code will have little impact on York.

"I'm confident that we are up to the game already," he said. "We have put a lot of effort into hygiene. I am sure there will be some things we can learn, but hopefully we are already there or thereabouts."

Tackling MRSA

Figures released by the Department of Health this week show that the number of patients at York Hospital infected by MRSA fell slightly last year, from 31 in the year to March 2004 to 28 in the year to March 2005.

The result puts the hospital mid-table in the national hospital MRSA infection league. Birmingham Women's Health Care Trust has the best record, with no cases of MRSA infection last year. Ironically, Birmingham University Hospital was worst, with 152 cases.

Although slightly down on last year, York has made little progress in the four years since MRSA infections began to be properly monitored. In the first year of monitoring, up to March 2002, the hospital had just 27 cases.

Mike Proctor, the hospital's chief operating officer, admitted he would like to see York doing better. "But we believe we are doing all the right things," he said. "We have a target of 12 cases by 2008. That's the one on which we will be judged."

To put the problem into perspective, 69,000 patients passed through the hospital last year, so 28 cases out of 69,000 doesn't seem too bad. MRSA, however, is only one of a number of hospital-acquired infections that the new hygiene measures are designed to tackle.

Updated: 11:26 Friday, June 24, 2005