Infection Control

December 20, 2008

Ireland’s first National Isolation Unit was opened yesterday by the Minister for Health, at the Mater Hospital in Dublin.  The unit has 12 beds in total and will be used for patients who contract highly infectious diseases such as tuberculosis, SARS and pandemic influenza.  It will also be used to treat patients with other infections including HIV, hepatitis B & C, meningitis, MRSA and malaria. This all sounds pretty good until you stop to think about it more deeply.

hospital-hygiene

Firstly, I was amazed to learn that this highly specialised ‘state-of-the-art’ facility with it’s own infectious diseases multidisciplinary team, is actually the first of it’s kind in the whole country. Six of the isolation beds in this new unit will  be under negative pressure to help prevent airborne transmission of infection by microscopic droplets. Two of the isolation rooms will have different air handling systems to enhance infection control. It begs the question as to what has been happening with highly infectious patients up until now? I know that some of bigger public hospitals already have isolation units which are used to hoard all the MRSA infected patients together but they do not have any specialised facilities.

And secondly, with healthcare associated infections (HCAI) such as MRSA and C. diff now endemic in Irish hospitals, it strikes me that it might make more sense to use the isolation units for the patients who are clear of HCAI’s, to keep them free from contamination?


Need I Say More?

October 14, 2008

Orla Tinsley suffers from cystic fibrosis. Earlier this year, Orla received a People of The Year award for her campaigning in the Irish Times on behalf of cystic fibrosis sufferers.

Ireland has the highest incidence of CF in the world and to it’s shame, it can also claim to have the highest mortality rate and the lowest life expectancy for CF sufferers. The critical issue here is the limited availability of suitable isolation facilities in Irish hospitals. For optimum management of cystic fibrosis, patients require isolation in individual en-suite rooms to prevent cross-infection occurring but CF patients are being denied this opportunity. Instead, these vulnerable patients must present themselves to A&E where they are exposed to high risk infections while they await admission to a hospital bed. They are then transferred to a mixed ward to be nursed alongside mainly geriatric patients with a variety of illnesses. This practice beggars belief. The high rate of MRSA infection in Ireland has done little to ease the plight of the CF population. Not only is MRSA a constant threat to immuno-compromised CF patients, it’s prevalence has meant that the extremely limited supply of isolation rooms have instead been prioritised for MRSA infected patients.

I’ve written about Orla before to document the appalling hospital conditions which she and many other cystic fibrosis patients must endure.  CF patients have been waiting for more than a decade to have a dedicated CF unit built at St. Vincent’s Hospital in Dublin and they are quite literally sick waiting.

Here is her account of her recent visit to hospital as published in today’s Irish Times.

“Dear diary: It’s Tuesday and I’m back in hospital for another blast of treatment for my cystic fibrosis, writes Orla Tinsley

I … ENTER St Vincent’s hospital in Dublin as I need treatment for an exacerbation of my cystic fibrosis. I have two options. I can go to A&E and wait on a trolley for a bed, or I can go home and wait on a waiting list.

Although my home is safer, I choose the A&E. I can’t continue in college or do the things I want to do if I am unwell, so I wait on a trolley.

A special type of needle, called a gripper, is used by most CF patients who have frequent infections. I need one now, but no one in A&E is qualified to put it in. A nurse from the designated CF eight-bed ward is called and comes down to put it in for me.

I am on a trolley in A&E and this procedure requires a certain amount of exposure. The porters are nice, the nurses are nice – they are both busy.

We ask if there is somewhere private for me to get my needle put in. There is nowhere. The specialised nurse and I think of what to do, she decides to take me out of A&E to try and find a room in the main hospital.

The A&E nurse stops us.

For a procedure that requires the utmost cleanliness, she says we can use the bathroom. The toilet in a busy, infection-ridden A&E is open to us.

We leave the department for the main hospital. It is after hours, treatment rooms are closed and wards pose a cross-infection risk. We eventually find an open door in a room that we know is clean and use it.

I go back to my trolley in A&E wishing I could have slept in that room. In A&E a nurse comes to give me my nebuliser through an O2 cylinder. I tell her that there are nebulising sets on the CF ward; if she could just ring them up she could get one. I’m sorry I didn’t bring my own, but she doesn’t understand what I’m saying. I explain twice more, then a porter who had been listening steps in. He tells her to leave it and goes up to the ward to get it.

There is no plug near the trolley I am on and so I have to wait before I can have it. I get moved to another square of the wall so that I can take my nebuliser. I then get moved into a curtained area for the night, and I am relieved.

The next day I am moved out to another curtained area. The nurse minding me is nice but busy, and late giving me one of my drugs. I ask her three times over the next few hours. Being on this drug long-term can affect kidney function, so the morning time is the best time to have it.

I use my mobile to call my CF nurse, who calls the A&E department and asks them to give me the drug. I still do not get it. I try calling my CF nurse again, but then my battery dies.

I walk up to their office and they call again, frustrated for me. They should not have to sort this out. I go back to A&E and get it.

Late that night I get a bed on the semi-private ward. It’s Wednesday night. I am in a room with a young girl, a lady with cancer and two elderly patients.

I am aware from the time my aunt was dying with cancer that I am not allowed to be around immune-suppressed cancer patients. Over the next few days I find out that the lady is in fact immune suppressed.

I am a danger to her, and I don’t think it’s a good thing to tell her.

One night the breathing of the elderly lady in the bed beside me gets worse. The next day her family are by her bedside and they keep apologising to me that it’s happening in my room. They are so, so sorry.

I tell them please, it’s not your fault. And I feel guilty that they feel so bad about it as they watch their mother die.

Another woman comes in, a new patient replacing the young girl. She is coughing violently, but seems pretty happy. She makes a phone call to a friend to tell her that at least she doesn’t have double pneumonia, like her neighbour, she only has pneumonia.

I feel the room shrinking.

She tells her friend on the end of the line: “Don’t get the sliced melon from Marks and Spencer . . . It’s right inside the door, I want the diced one,” she giggles down the line.

At that same moment a relative behind the curtain of the lady beside me says: “Is she gone? Yeah? Oh God.”

The other woman continues to talk on her phone. After the lady passes away her body stays in the room for three hours.

That night, another lady with cancer moves into the bed beside me. Her temperature has gone up so she had to come in. Both ladies with cancer are so much fun to be in a room with.

The lady who had just moved in is only starting to lose her hair, the other lady had already lost hers. She wants a “Posh Becks” hairstyle, like Victoria and David Beckham when her hair grows back. We giggle at the thought.

At every opportunity I leave the room to talk to the nurse about trying to get moved. Bed management are aware of the situation, but there is nowhere to move any of us.

I talk to the ladies about it and tell them I might write about it. They are meant to be in isolation, but they are not. I am a risk to them, and then there is the lady with pneumonia in the corner, who poses a risk to us all.

I try to sleep with a mask to protect myself and the people in the room, but it is sweaty and a bit restricting for breathing.

On Monday I am given the option of moving to a two-bedded room on the same ward. I accept and find myself in a room with one the kindest, most vivacious elderly ladies I have ever met. She is chatty, but knows when to leave me alone. She is a pleasure to share with, but even our camaraderie can’t disguise our different needs.

As she is unable to leave her bed, she needs the commode two or three times during the night. She is the nicest woman in the universe, but my cough is already making it difficult for me to sleep.

The rattle of the commode at 12.30am, 4.00am and 6.30am rips into my ability to rest. There is a smell too. It is not her fault, but I cannot sleep properly.

One day she is complaining of discomfort and extra swelling in her legs. I only become aware of it because this woman is not a typical patient.

She never complains, even though she has a chest drain in, which makes it impossible for her to walk around. That morning she complains a lot about her feet.

It is three hours at least since someone has been at her chest drain and I notice that it is clamped. I tell the nurse, he comes in straight away and deals with it. I ask a medical person about it later – chest drains should never be clamped unless they are about to be removed.

She feels better, we’re getting on well, but I’m still not sleeping well. We keep in good spirits chatting, and she tells me about how her handbag was taken while she was in hospital. Luckily her daughter was with her to cancel her cards and keep her afloat.

It wasn’t her bank card so much, but being without her reading glasses really upset her. She was told a member of security would come back to investigate the situation, but they didn’t.

There are 28 cystic fibrosis patients in as I write this, and there are eight single en-suite beds. The beds are allocated on the advice of the microbiologist. There is a long list to get into them. The eight single en-suite beds are on a new ward, but there are also general beds on that ward too for patients who do not have cystic fibrosis.

In February this year former junior minister for health Pat Gallagher said 14 single en-suite rooms would be available by the end of the summer for CF patients. I remember being told early this year that there would be six more, in another area in the hospital.

I ask a person in officialdom what is going to happen with the six other beds we desperately need until our unit comes at the end of 2010. This person tells me that there are no plans for six beds, that they have heard nothing about it. They have no funding; they have other things to sort out first. They want to see how the eight single rooms work.

Meanwhile, the winter months are coming, the number of cystic fibrosis patients needing inpatient treatment will rise. Some will refuse to go into hospital and risk damaging themselves, some will come to A&E, and risk damaging themselves.

Others can be treated at home, but if that doesn’t work they will have to come in anyway. Those who are not in the eight beds will continue enduring cross-infection, exhaustion and fear every time they are in hospital.

We will all think of the recession and what that means for us. We will comment to one another that 2010 seems like a lifetime away, and feel sick to our stomach that some of the 1,100 people in Ireland with cystic fibrosis will not see it.”

This article is published courtesy of the Irish Times online.


A Balancing Act

April 19, 2008

I listened with interest to Prof John Crown on the Late Late show last night as he outlined the failings within our health service. John Crown is a leading consultant oncologist working in the front line of the Irish health service and he doesn’t mince his words. He believes that the consultant’s contract as currently presented by the HSE, is a fiasco. He described it as an apartheid contract for an apartheid system of healthcare. Today, I heard that the Irish Hospital Consultant’s Association (IHCA) has accepted the HSE’s proposals and will be recommending the contract to it’s members in a ballot later this month. Meanwhile, the Irish Medical Organisation (IMO) is still refusing to come on board and has today requested third party mediation to resolve the problems. On one side, we have a government that insists on perpetuating a 2-tier system of healthcare despite the consensus of opinion which believes that a single tier health service is the way forward. On the other side, we have doctors who don’t like being put under the thumb by administrators who will decide their working hours. This contract has already been four years under discussion and I have to agree with Prof Crown, it has the potential to be a fiasco.

We have a health service in Ireland that offers a high standard of care but the care is not optimal. According to John Crown, this is due to ‘mal’ funding rather than underfunding. When the allocation of money from the HSE runs out, services are cutback at the expense of patient care. Treating patients costs money but It costs the system nothing to have patients on waiting lists. We have a health service run by civil servants instead of having a medical leadership structure in place. The policy of co-located hospitals as proposed by the Progressive Democrat (PD) health policy, is set to cause an even wider divide between the public and private systems. Each system will be differently funded, further adding to the complications. The concept of co-location ultimately means that services are duplicated in the one location. This is neither efficient nor cost effective . The co-located private hospitals already in existence, tend to be small and have sub-optimal expertise in place. As a holder of private health insurance, I can personally testify to this having once faced the decision of having to choose between standard of accommodation and standard of medical care. I was very unwell in A&E at the time and required admission for investigation. As I was known to be infected with MRSA , I required isolation facilities in order to be admitted to the hospital. There were single rooms available in the co-located private hospital but the physician under whose care I was to be admitted, worked only in the public hospital where no isolation facilities were available at that time. This dilemma typifies all that is wrong with the plans for co-location and the divisive nature of the consultant’s contract. I had no problem choosing medical expertise over comfort but I should never have had to make that choice. Why does healthcare have to so divisive? If you’re sick and in need of hospitalization, the type of care you receive shouldn’t be dictated by your ability to pay.

John Crown is in no doubt that the way forward for our health service is a single-tier, not for profit system of healthcare based on a universal system of social insurance. He makes no apology for speaking out about the deficiencies within our health service. As long as there continues to be vested interests and a burgeoning bureaucracy in control of our health service, the system is doomed to fail. The future of the consultant’s contract remains in the balance.


A Lifeline

March 17, 2008

a-lifeline.jpgAnyone who’s ever read a book they can’t put down, will know exactly what I mean by compulsive reading. The story draws you in and you find yourself totally captivated until the last page is reached. Well, last night I found myself in exactly the same situation only on this occasion it wasn’t a book I was reading. It was blog and it’s stunning!


On looking through my blog stats, I noticed several visits from a referrer called Distant Rambler. I didn’t recognise this name and on investigating further, I couldn’t believe my luck at the blog I’d found. It’s beautifully written, very moving and is totally spell-binding. I can honestly say that of all the blogs I’ve ever read about patients and their medical stories, this one stands out way above the rest.

This inspirational blog is written by Laura, a 28 year old with a PhD, who is presently in hospital undergoing treatment for ALM, an acute form of leukaemia. It is in effect, cancer of the blood. This is not Laura’s first time tackling ALM as she was first diagnosed with leukaemia when aged just 12 years. Her cancer recurred last year but this time she has also had to battle a tumour on her back. She spent her birthday in isolation and also missed out on a family wedding. It takes pure grit and determination to achieve a PhD and these qualities shine through in her approach to her illness. Laura has recently undergone a bone marrow transplant (BMT) and is presently back in isolation, counting down the days until her release. She writes her blog like a diary, detailing all the daily ups and downs of her journey with cancer. Her story is written with such clarity and honesty, it’s quite breath-taking. Put simply, Laura’s life is on the line. She has spent a great deal of time in hospital undergoing intensive chemotherapy and despite suffering many setbacks along the way, she still manages to find humour in her situation. I love her writing – Laura does not beat about the bush, she gives it to you as it is. She is incredibly brave in the face of adversity and deserves huge admiration.

Today is Day 17 post-transplant for Laura – she received her third bone marrow transplant on 29/02/08 and has spent the last 17 days in complete isolation. Today is also St. Patrick’s Day, a day when Irish citizens are celebrating around the world. Laura is too ill to celebrate but through her blog, she still managed to wish everyone else a happy day. Her laptop is her lifeline, her contact with the outside world. Her blog provides her with a welcome breathing space from her illness and continuing treatment. Laura is feeling very low at the moment. Please, could I ask you to drop by her blog and let her know that you are thinking of her. You will be, quite literally, throwing her a lifeline.

I hope tomorrow is a better day, Laura.


MRSA and Infection Control

February 13, 2008

A recent report has shown that Ireland has the third highest rate of incidence of MRSA in the EU. The over-prescribing of antibiotics, poor hospital layout and poor hospital and personal hygiene are the main factors responsible for the high rate of MRSA infection. Following my own experience with MRSA, I concluded that our health service has serious infection control issues to resolve.

Some years ago, I was re-admitted to hospital due to complications (orbital cellulitis) following a complex frontal sinus operation. I was assessed in A&E before being transferred to a 5-bedded general ward. I received intensive IV antibiotics but my symptoms failed to respond to treatment and three days later a nasal swab which had been taken on admission, revealed that I was suffering from an MRSA infection. I was immediately moved to an en-suite single room and barrier nursed in isolation while undergoing specialised intensive treatment. So the delay in getting this result had meant that for three days I had been an infection risk to the other patients in the room. This regrettable situation came about simply because our hospitals do not have adequate funding or the laboratory resources to fast-track MRSA screening, and as a result infection control suffers.

Over the following months my infection gradually worsened and I was to be re-admitted to hospital on three further occasions for treatment, each time being processed through the A&E department before being transferred to a hospital bed. This policy would question infection control strategies. By this stage I was an officially ‘labelled’ MRSA patient and on arrival in A&E, I would be quickly escorted to a tiny walled-off area of the unit. This ‘box’ was the HSE’s answer to infection control and it really was worse than a bad joke. It had no en-suite facility so during the many long hours I spent in this hell hole, I used the same toilet facilities as all the other patients thereby defeating the purpose of isolation. No sign of an infection control protocol here. I used to dread the looks I got whenever I emerged from those four walls.

On another occasion after spending the night in A&E, I was transferred to a single room on a busy medical ward. Again this room had no en-suite facilities and I was expected to use shared toilet facilities. No sign of an infection control protocol here. The following morning I was told I was to be moved to the MRSA isolation unit to complete my treatment as my room was needed for another highly infectious patient. I was not happy about this as I instinctively felt that my own recovery would be compromised by moving to the MRSA unit where there is a high risk of cross-infection. If my room had been needed for a dying patient, I would have obliged but it was not my fault that the hospital didn’t have an adequate supply of individual isolation rooms for infection control. I’m afraid I dug my heels in and refused to move despite the huge pressure applied. I’m usually a very amenable sort of person but on this occasion I’d had enough and wasn’t prepared to risk my own health to facilitate any bed manager. Once the fuss had died down, I was quietly told that I’d earned huge admiration from the medical staff for standing up to the powers-that-be at the hospital.

As it transpired, several weeks later I was again re-admitted to the hospital having developed chronic osteomyelitis in my skull and on this occasion I did end up being transferred from A&E to the MRSA isolation unit. I’ve already written about the slack infection control policy here in another post. This unit was everything I’d feared, and worse but after weeks of treatment there I did get the necessary all-clear to be allowed to complete my treatment elsewhere. I assumed I was being transferred to a single room but you can imagine my horror when I found I’d been put back into the same 5-bedded ward where two months previously, I’d first received the diagnosis of MRSA. I again instinctively felt that I posed an infection control risk to the post-operative patients in the neighbouring beds. Despite a fear that I’d be transferred back to the awful isolation unit, I pointed out my concerns to the staff and luckily for me on this occasion, a single en-suite room was quickly made available. This action however sadly confirmed that my concern was justified.

It really is hard to believe the ignorance and confusion that still exists in the whole area of infection control. Comprehensive updated guidelines have been drawn up but they cannot be implemented because of inadequate resources, sub-optimal infrastructure and a lack of access to relevant expertise locally. Laboratories are chronically understaffed and cannot maintain even routine diagnostic work. MRSA is a huge problem that’s not going to go away unless infection control is properly tackled. In the meantime, the response from the HSE has been to spearhead a campaign to place the onus on patients to ensure that medical staff have clean hands. Proper hand hygiene is a major factor in stopping the spread of MRSA but it should be part of a multifaceted approach. If Ireland is to reduce it’s incidence of MRSA, the HSE needs to stop playing silly games with our lives and declare war on the superbugs.


Life or Death

January 24, 2008

There’s been a lot of hype recently in Ireland about the appallingly inadequate hospital services for adult patients with cystic fibrosis (CF), and rightly so. Put simply, our Government’s failure to provide a dedicated CF unit in this country, is costing lives.

The critical issue here is the limited availability of suitable isolation facilities. For optimum management of cystic fibrosis, patients require isolation in individual en-suite rooms to prevent cross-infection occurring but CF patients are being denied this opportunity. Instead, these vulnerable patients must present themselves to A&E where they are exposed to high risk infections while they await admission to a hospital bed. They are then transferred to a mixed ward to be nursed alongside mainly geriatric patients with a variety of illnesses. This practice beggars belief. The high rate of MRSA infection in Ireland has done little to ease the plight of the CF population. Not only is MRSA a constant threat to immuno-compromised CF patients, it’s prevalence has meant that the extremely limited supply of isolation rooms have instead been prioritised for MRSA infected patients.

When I was first diagnosed with an MRSA infection following surgery, I was hurriedly moved out of a general ward into an en-suite isolation room to be barrier nursed while receiving intensive IV treatment. I felt like vermin and in reality, I represented a high risk to those patients whose immune systems are compromised by disease or treatment. I was eventually discharged home on oral antibiotics but the infection recurred and I was re-admitted through A&E for further IV treatment in a single isolation room. I was again allowed home on oral antibiotics but the infection worsened and I soon had to come back into the hospital. On this occasion I was transferred from A&E to the MRSA isolation unit where all patients with MRSA are nursed together. This unit was full of elderly patients, it was poorly ventilated and I felt distinctly uncomfortable with the high risk of cross-infection there. During my stay, I would spend the evenings sitting outside the door to the unit to get fresh air and to escape the blaring televisions. None of the staff ever objected to this practice. As my health improved, I soon ventured further afield to use the hospital coffee bar as a venue for meeting visitors. Nobody advised me otherwise and indeed, I often met doctors I knew while on my travels and they’d stop for a friendly chat. The point here is that as a carrier of MRSA, my outings put other patients at significant risk of cross-infection. This stark reality was brought home to me when listening to the recent public debate on CF issues. At the time, my only concern was self-preservation but now I realise that I should never have been allowed to wander the hospital corridors. If anyone is to blame, it is the hospital authorities for their slack policy of infection control.

Ireland has the highest incidence of CF in the world and yet we have the highest mortality rate and lowest life expectancy. CF patients have been waiting for more than a decade for a dedicated CF unit to be built and they are quite literally, sick waiting. Our Government has failed miserably in it’s duty of care to these young citizens. Lives are being shortened and young people are dying as a consequence of our inadequate hospital services. This really is a matter of life or death.


Do you think I’ll get the job?

January 4, 2008

With the New Year upon us and my health now stabilised following surgery last year, I’m thinking about returning to work. I got out my CV recently to bring it up to date but there are a few gaps in it which will take some explaining.

I first entered the workforce thirty years ago, full of enthusiasm and ready to take on the world. Since then my career path has veered a bit off-course but I reckon I’ve got some damn good statistics to show for it. I did the figures today.

Since leaving school I’ve been admitted to hospital 42 times (approx), not counting day surgery or days spent in A&E. Some of these stays were for lengthy periods, 12 were emergency admissions and I’ve arrived by ambulance on three occasions.

I’ve undergone 30 surgical operations under general anaesthetic, again not counting day surgery and I’ve been the sole candidate on the operating list three times due to the extent of surgery.

I’ve had 2 post-operative haemorrhages, one requiring a transfusion and the other necessitated an emergency return to the operating theatre.

I’ve had 9 separate admissions to hospital for intra-venous treatment with a combination of antibiotics. The longest period on continuous I.V. treatment was 4 weeks and that was spent in an MRSA isolation unit.

And that’s just my in-patient record. Otherwise, I’m in fine fettle 😀

What do you think I should say at interview presuming I get that far, when I’m asked to explain the gaps?