by Dr. Ann Bradshaw
According to SAGE’s briefing paper to Government, published February 12th 2021, but considered at the SAGE 78 meeting on January 28th, in the first wave of Covid infections up to 40.5% were caught in hospital. An earlier version of this paper was presented at SAGE 63 on October 22nd 2020. So the Government was aware of this three months earlier but does not appear to have publicised it. This shocking statistic is brought to life by the death of Captain Sir Tom Moore, who tested positive for Covid in a Bedfordshire Hospital, where there were significant numbers of similar cases. So it is both surprising and shocking that hospital spread has hardly been considered by the Government or indeed, been of concern to the media. Why is this?
Hospital spread infection is not a new problem. In 2008 the King’s Fund published a Briefing Paper on Health Care Associated Infections in hospitals, subtitled “Stemming the Rise of the Superbug”. MRSA (Methicillin Resistant Staphylococcus Aureus) had increased dramatically: from fewer than 100 incidents in 1990, to more than 5,000 in 2001. Although part of the increase was probably the result of better identification and reporting. There were nearly 50,000 cases of clostridium difficile in 2007 reported in acute trusts in patients aged 65 years and over. Between 2004 and 2006, the number of cases of C difficile rose steadily from 44,563 to 55,634.
The King’s Fund recommendations were for hand hygiene, a ‘clean your hands’ campaign and a ‘bare-below-the-elbows’ dress code for health care staff aimed at facilitating effective hand decontamination. Both these were implemented in 2004 and 2007 by Government. Isolation of infected patients was also recommended. Although the King’s Fund recognised that a hospital’s capacity to isolate patients depends on the design of the building, particularly the number of single rooms, as well as an ability to move patients around, which could be affected by levels of bed occupancy.
These two issues of isolation and hospital hygiene are extremely relevant to the Covid situation today. The importance of isolating contagious patients has been suggested by Jefferson and Heneghan but apparently this suggestion has been ignored by Government planners. And it is hard to see why Nightingale hospitals and some imagination with staffing were not used for this purpose (as I have written previously).
The second issue is that of hospital hygiene. When I trained as a nurse 1968-1971, hospital hygiene was drilled into us student nurses. Doing a dressing for a patient, for example, meant washing down a dressing trolley in the clinical room twice, first with a soap and water substance then with an antiseptic – Hibitane – and laying out the trolley. Dressings were only carried out in the afternoon when any dust created by the ward work in the morning had settled. Dressing a patient followed a procedure. It started by explaining to the patient and making him or her comfortable. Where the dressing pack was placed on the trolley, how the pack was opened was prescribed. So too were the steps needed to perform the dressing and to dispose of contaminated material. Before each step hand washing was required.
When I returned to nursing after a career break in the 1980s, the new nursing argued that what I had learnt was routinised, task orientated, ritualised and unnecessary. There was no evidence to support this way of laying up a trolley for a dressing. In fact, research showed (I was told) there was too much unnecessary handwashing, and the dressing trolley just needed to be socially clean (wipe off any blood or other liquids, for example). This new way of thinking can be seen in an influential article at the time in the Journal of Advanced Nursing which claimed to be ‘research based’ (Bree Williams and Waterman 1996 48-54) that argued ritualistic practices including too much handwashing gave a false sense of security.
The strict discipline of nurse training in the period I trained and the fact of a prescriptive national common syllabus issued and examined by the General Nursing Council of England and Wales was reflected in the uniform requirements. This description from a St Bartholomew’s Hospital nurse of hospital uniform 1940-1985, reflected my own tradition:
Nurses took a real pride in their uniforms and were expected to wear them correctly! Bart’s was no exception, and it was made clear at the Preliminary Training School that uniforms were to be worn “in the correct manner”. Strict discipline was enforced on this, and we also took a real pride in wearing our uniforms. On starting our training we were told that make up, nail varnish, wrist watches and jewellery were all forbidden!
This strictness was for the purpose of preventing cross infection and possible injury to patients. Wearing a ring other than a wedding band might scratch a patient. And so I was struck by a recent photo in the press of a health care worker with a wrist watch on, and jewellery and a pony tail, vaccinating a patient.
So when I am told by the current nursing leadership that I am harking back to a non-existent golden age, I can show that in fact, although there were undeniable problems with healthcare in the past, there was much that should not have been rejected. The old system of nursing, with its detailed, prescriptive common syllabus and procedures, did contain routine and set tasks in a medical model but had good reasons behind it. Its rejection in favour of the much vaguer Nursing and Midwifery Council curriculum of today, with all its variability, has not necessarily always resulted in improvements. It is arguable that hygiene procedures had to be restored by Government intervention when the new system resulted in increased hospital infections. Routine is not always bad – it can serve a vital purpose. It is truly horrifying that 40.5% could be the number of people catching Covid from hospital. As Nightingale wrote in Notes on Nursing: “The very first requirement in a hospital is that it should do the sick no harm.” So I wonder what she would make of that statistic!
Dr. Ann Bradshaw is a retired senior lecturer in adult nursing at Oxford Brookes