Journal of Orthopaedic Nursing (2008) 12, 136–138

www.elsevier.com/joon

Journal ofOrthopaedic Nursing

OPINION

The true cost of health care associated infection

Mark Cole MSc, BSc (Hons), DN (Lond), Diploma in Infection Control(Lecturer) *

University of Nottingham, Grantham School of Nursing, 101 Manthorpe Road, Grantham,Lincolnshire NG31 8DG, United Kingdom

The cost of health care associated infection (HCAI)should not be considered merely in terms ofmoney, although it is an immense drain on limitedhealth care resources. Nursing in particular hasbeen singled out to carry the brunt of media com-ments about dirty wards and practices. The imageof the nurse has become tarnished in several sensesover this issue. The following comments are onenurse expert’s views on the current dilemma.

HCAI is a global health phenomenon that per-vades every healthcare facility and system, regard-less of the resources available (Pittet et al., 2008).In the UK it is thought, to affect ten percent ofinpatients annually, causing 5000 deaths and cost-ing £930 million (National Audit Office, 2004).There is of course nothing new about iatrogenicinfectious disease, as long ago as the 19th century,perceived wisdom contended that hospitals weremore likely to spread infections than to stop them(Ayliffe and English, 2003). In the UK however, inrecent years the topic has become highly politi-cised, receiving considerable attention from themedia (McConnell, 2007), policy makers (Depart-ment of Health, 2007, 2006, 2003) and expert clini-cians (Pratt et al., 2007, 2001). Historically popularfaith in the NHS was sustained by limiting expecta-tions to what it could afford within the resourcesallowed through the government (Tudor Hart,1998). However, a central theme running through

1361-3111/$ - see front matter �c 2008 Elsevier Ltd. All rights reserdoi:10.1016/j.joon.2008.07.002

* Tel.: +44 1476 565232.E-mail address: mark.cole@nottingham.ac.uk

the reform of contemporary healthcare systemshas been the provision of a more consumer respon-sive service with the tacit assumption that patientexpectations have increased (Laing, 2002). In the21st century it would seem that people find the no-tion of HCAI unacceptable. In this they would ap-pear to have the support of Professor Deurden,the Department of Health’s Inspector of Microbiol-ogy and Infection Control, who asserts that we canno longer accept these infections as normal (Duer-den, 2008).

Raising the profile of infection control has indeedresulted in a greater commitment and ownership ofthe problem of HCAI at a senior management level.It has enhanced methods of surveillance, seen theimplementation of clinical practice protocols, wit-nessed the introduction of target setting and perfor-mance management and probably, above all else,generated significant financial support for servicedevelopment. However, in increasing its profile,infection control is also fuelling patient expecta-tions. Recounting his experiences of August lastyear; Lord Mancroft the 50-year-old vice chairmanof the Countryside Alliance, encountered ‘‘filthywards and nurses who were slipshod, grubby andlazy’’. A plethora of patient blogs set up in the wakeof this, indicate that Lord Mancroft’s experiencewas not unique and according to a survey of hospitalchief executives released by theNHSConfederation,‘‘Patients are nowmore scared of catching an infec-tion than of going under the knife’’ (Hinsliff, 2005).Although expectations are said to be unique to the

ved.

The true cost of health care associated infection 137

individual who holds them, they are governed byhow one understands the world, and are formed inrelation to the social and cultural contexts withinwhich they are located (Janzen et al., 2006). Themedia spotlight of HCAI and its portrayal of ‘‘super-bugs’’ as an amorphous enemy that can be defeatedhas done much to create the notion that a back tobasic policy based upon strong leadership and goodpersonal hygiene will win the day. What is more, itcould be argued, that this strategy has receivedthe tacit approval of experts who have enjoyed thefruits of the increased attention and resources thathave been afforded the topic.

Although relatively uncommon, infection follow-ing orthopaedic surgery has been described asdisastrous and is associated with high rates of mor-bidity and medical costs (Hogg et al., 2005). Injoint replacement surgery patients can suffer upto three interventions (implantation, removal andre-implantation), and this may result in a poorfunctional outcome (Barberan, 2006). As such theexpectations of patients undergoing orthopaedicsurgery and their concerns in relation to acquiringan infection when in hospital might be high. Indeedencouraging patient involvement forms a part ofUK improvement campaigns and challenging thehand hygiene practice of staff is one example ofthis. Whereas it can not be denied that makingone accountable for ones own actions is a goodthing, it is questionable whether the representa-tion of HCAI in simplistic terms and the framingof non-compliance as a matter of blame and moralresponsibility indicate the true complexity of thetopic. Regrettably even the most optimistic ac-counts of HCAI, concede, that the overwhelmingmajority have a sense of inevitability. Moreover,as important as they are, those that are prevent-able require more than good personal groomingand transformational leadership. Reducing HCAI re-quires best practice that goes beyond the point ofcare and should include, among other things: a re-view of isolation facilities, bed occupancy, staffinglevels and education and training.

Nevertheless, the media and its pervasive HCAIdiscourse remain important and influential sourcesof information that help to construct the public’sunderstanding of infection control (Gill et al.,2006). As welcome as the increased attention andresources may be, accompanying them has beenan exponential rise in patient expectations. Infec-tion control has created its own Sword of Damoclesand it now needs to deliver sustained improve-ments to an increasing frail, high risk population.Patients of course have the right to expect the bestpossible care and improvements in practice will

prevent many of the appalling consequences ofHCAI. However, the implicit, and at times explicit,assumption that all HCAI are the result of poor careand can be prevented by the implementation ofprescriptive rules is a less than honest account.The microbial colonisation of man is a normal, sym-biotic process that becomes clinically significantwhen patients have the conditions that require highimpact interventions. In this, health care settingsprovide fertile breeding grounds. Health care work-ers should expect to find a public, who are para-doxically, better informed but who may haveunrealistic expectations. To date it has been themedia and policy makers who have been largelyresponsible for determining the patients under-standing of HCAI. Clinicians have, to a point, stoodby and allowed this to happen. It is time for clini-cians to become more active in shaping the publicsunderstanding of HCAI. At a strategic level thiscalls for greater candour when discussing all ofthe strategies that are implicated in reducing hos-pital infection and their cost both in financial termsand the impact this may have on waiting lists. At apatient care level there needs to be a more honestaccount of the aetiology of iatrogenic disease andregrettably an acceptance that current medicalscience has limitations in the prevention of HCAI.

References

Ayliffe, G., English, M., 2003. Hospital Infection: From Miasmasto MRSA. Cambridge University Press.

Barberan, J., 2006. Management of infections of osteoarticularprosthesis. Clinical Microbiology and Infection 12, 93–101.

Department of Health, 2003. Winning Ways: Working Togetherto Reduce Healthcare Associated Infection in England.Department of Health, London.

Department of Health, 2006. The Health Act: Code of Practicefor the Prevention and Control of Health Care AssociatedInfections. Department of Health, London.

Department of Health, 2007. Saving Lives a Delivery Programmeto Reduce Health Care Associated Infection. Department ofHealth, London.

Duerden, B., 2008. Tackling healthcare associated infections inthe NHS – progress so far. British Journal of Infection Control9, 4–7.

Gill, J., Kumar, R., Todd, J., et al., 2006. Methicillin resistantStaphylococcus aureus: awareness and perceptions. Journalof Hospital Infection 62, 333–337.

Hinsliff, G., 2005. MRSA Checks Before Patient go in. Availablefrom: <http://observer.guardian.co.uk/uk_news/story/0,6903,1504692,00.html>.

Hogg, S., Baird, N., Richards, J., 2005. Developing surgical siteinfection surveillance within clinical governance. ClinicalGovernance: An International Journal 10, 24–36.

Janzen, J., Silvius, J., Jacobs, S., et al., 2006. What is a healthexpectation? Developing a pragmatic conceptual model frompsychological theory. Health Expectations 9, 37–48.

138 M. Cole

Laing, A., 2002. Meeting patient expectations: health careprofessionals and service re-engineering. Health ServicesManagement Research 15, 165–172.

McConnell, J., 2007. Public reporting in the UK of hospitalinfections. Journal of Hospital Infection 65, 189–190.

National Audit Office, 2004. Improving Patient Care by Reducingthe Risk of Hospital Acquired Infection: A Progress Report.The Stationery Office, London.

Pittet, D., Allegranzi, B., Storr, J., 2008. Infection control as amajor World Health Organization priority for developingcountries. Journal of Hospital Infection 68, 285–292.

Pratt, R.J., Pellowe, C., Loveday, H.P., et al., 2001. The epicproject: developing national evidence-based guidelines forpreventing healthcare associated infections, phase 1: guide-lines for preventing hospital-acquired infections. Journal ofHospital Infection 47 (Suppl.), S1–S82.

Pratt, R.J., Pellowe, C.M., Wilson, J.A., Loveday, H.P., et al.,2007. Epic 2: National evidence-based guidelines for pre-venting healthcare-associated infections in NHS hospitals inEngland. Journal of Hospital Infection 65, S1–S64.

Tudor Hart, J., 1998. Expectations of health care: promoted,managed or shared? Health Expectations 1, 3–13.

Available online at www.sciencedirect.com