Investigation into three deaths from superbug infection at Arrowe Park Hospital

A report to the hospital board says it is vital improvements are made at once to avoid any further harm.

And it reveals the hospital-wide outbreak of clostridium difficile infection (CDI) is a consequence of "a sub-optimal environment, poor practice in the control of infection, lack of facilities to isolate patients and insufficient priority being given to the control of infection."

In January of this year two patients died of CDI. The deaths were investigated as serious incidents and were reported to the NHS authorities.

The trust declared an outbreak of CDI in February - but as cases continued to be identified it was extended and re-declared in May.

A further superbug-related death was reported that month, which is now under investigation as a serious incident.

The first two deaths were around the same time and the investigation team named patient flow and high bed occupancy which prevented effective environmental cleaning, as the main contributory factors.

A contaminated environment was named as one of the causes of cross-infection during the period of increased incidence of CDI.

The report, compiled by the trust's associate director of nursing Jay Turner-Gardner, says "overwhelming themes" have been identified during the present outbreak including:

Failure to isolate the patient in a timely manner

Delays in sample taking

Inconsistent cleaning standards

Cluttered environments

Poor maintenance of the hospital, which does not permit effective cleaning

It says it is essential staff are reminded of their roles and responsibilities regarding patient safety and how they have an impact on the infection prevention agenda.

De-cluttering, maintenance of the environment - including replacement of some equipment - and effective cleaning are the main issues that need to be addressed.

As a result of the outbreak several steps already have been taken.

A communication campaign has begun and messages are displayed on screensavers trust-wide so "all staff can see key ways in which they can help."

Two wards have been identified to showcase how improvements can be made to promote clean safe care - wards 38 and 18.

De-cluttering has started across the trust and cleaning processes have been reviewed to "get back to basics" and simplify fundamental requirements.

In its conclusion the document states: "The hospital-wide outbreak is a consequence of a sub-optimal environment, poor practice in the control of infection, lack of facilities to isolate patients and insufficient priority being given to the control of infection.

"Many wards in Arrowe Park require repair.

"The nature of the environment and the facilities available means that the control of infection is particularly difficult.

"It is difficult to isolate patients because there are few side rooms.Most of these do not have en-suites and some are not available for the isolation of patients with infections due to conflicting priorities, patient flow and high bed occupancy."

Recommendations:

To avoid further harm, action is needed immediately in the following areas

De-clutter.

Effective cleaning with a cleaning programme that reflects the patient’s needs.

Replacement of inappropriate/damaged equipment to promote effective decontamination

Repair and ongoing maintenance of the patient’s environment.

Rapid identification and isolation of patients with diarrhoea

Restricting the movement of infected patients between wards

Re-enforce staff roles and responsibilities in keeping patients safe by preventing avoidable infections.

Reduce bed occupancy via improvement in patient flow