We can't export healthcare without hygiene

There is a very real chance that in the few minutes it takes to read this article someone in the UK will die from healthcare-associated infection (HAI). According to data from across Europe, HAI affects more than four million people a year, playing a direct or indirect role in almost 150,000 deaths. So the odds are that the problem is claiming another victim right now. It is neither a pleasant thought nor one that should provoke even a trace of complacency, since the odds are also that the vast majority of these deaths could be prevented. That they are not is a damning indictment of a weakness that seems scarcely plausible in the 21st century. It is not unknown for the issue of clinical cleanliness to rise up the socio-political agenda, normally in the wake of a major outbreak and a significant loss of life. Most members of the general public will have heard of MRSA, and many will have also encountered media coverage of the likes of Clostridium difficile (or C-diff, as it is invariably known in headline-friendly form). And yet, as a study published three years ago in The Lancet Infectious Diseases pointed out, cleaning’s effect in a healthcare setting has seldom – if ever – been accorded genuinely scientific status. However busy, overcrowded and cluttered hospitals might become, however fertile a breeding ground they might offer for dirt and disease, cleanliness is still assessed visually. This is not just woefully inadequate: in many instances it is potentially deleterious. Moreover, this is a problem that goes far beyond the enduring question of what might lurk in the grimiest nooks and crannies of any given ward or corridor. It encompasses equipment, the processes they facilitate and, by extension, healthcare delivered not only inside hospitals but outside them. As such, it demands a holistic approach and a complete change in thinking. Two considerations should be at the forefront of the necessary shift in philosophy. The first is that the established approach to the design of healthcare equipment too often prizes mere functionality over infection control. The second is the growing pressure to cut costs by transferring more and more treatment to the community, as a result of which shortcomings that might once have been largely confined to a hospital environment are at ever-increasing risk of occurring in a patient’s home. These concerns are perfectly encapsulated in the iconic “Gladstone” bag that doctors and nurses around the world have used to provide mobile treatment for the past 150 years. Its continued prevalence represents nothing less than an alarming example of modern-day professionals employing hopelessly outmoded equipment. After all, we might reasonably expect a few eyebrows to be raised if a doctor were to attend a house call on a penny-farthing and brandishing an array of hacksaws and mercury vials. Yet nothing is deemed amiss when his bag is the product of 19th-century wisdom. A study conducted at the Royal College of Art and supported by the University of Huddersfield and NHS East Riding of Yorkshire as part of the NHS at Home project shed a disturbing light on this systemic myopia. It found one third of a sample of bags used by nurses in the community carried the MRSA bug; 55 per cent were never cleaned; and only six per cent were cleaned once a week. These results are all the more disquieting when one factors in another key figure: diary analysis shows community nurses in the UK visit up to 17 patients a day, mostly for wound care. The only realistic response was to create a new bag. This radical update is constructed of non-permeable polypropylene white plastic and has easy-to-clean drawers and a hard surface that can be transformed into a hygienic treatment area. It is entirely free of the zips, pockets, fasteners and folds that for more than a century and a half allowed its predecessor to encourage bacteria and discourage cleaning. The bag was highly commended in the Department of Health’s recent NHS Innovation Challenge and will be commercialised next year. It is a step towards a new design ethos and the improvement of community healthcare. But action is required on a much wider scale. Unbelievably, in the UK there are at present no guidelines concerning the cleaning of doctors’ and nurses’ bags outside hospitals. In other words, a straightforward and apparently obvious measure to preserve patient safety remains entirely overlooked. Such apathy betrays our communities. We cannot export healthcare to the home while declining to observe the same hygiene standards that would ideally be applied in every hospital in the land. All conceivable efforts should be made to sanitise and safeguard treatment, irrespective of where it is delivered. If policymakers and the profession itself continue to neglect this fact, not least in an era in which community care is being propelled to unprecedented levels and the threat of HAI is rising in tandem, they will be failing in their duties. Worse still, they will be failing the patient population.